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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 1532 Results
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Anesthesia Patient Safety Foundation. September 6–7, 2023; Red Rock Casino Resort and Spa, Las Vegas, NV.
Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference will explore topics related to the theme of “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.”
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Rojas CR, Moore A, Coffin A, et al. Jt Comm J Qual Patient Saf. 2023;49:226-234.
Children with complex medical conditions are particularly vulnerable to medication errors. This article describes the development and implementation of a pharmacy-led medication rounding care model for children with medical complexity wherein clinicians and pharmacists conduct weekly reviews of all patient medications using a standardized checklist.
Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

Bilski J. Outpatient Surgery. February 2023;16-21

The concept of just culture was challenged in a high-profile medication error resulting in criminal charges for a nurse. This dialogue shares insights on the impact of the case on nurses, their profession, and patient safety.
WebM&M Case February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

Baldwin CA, Hanrahan K, Edmonds SW, et al. Jt Comm J Qual Patient Saf. 2023;49:14-25.
Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.
Pedrosa Carrasco AJ, Bezmenov A, Sibelius U, et al. Am J Hosp Palliat Care. 2022:104990912211400.
Patients with medical complexities who are receiving palliative care may be at increased risk for patient safety events. This cross-sectional survey found that patient safety concerns were common among patients receiving specialist community palliative care in Germany. Patients reported that physical disability, physical and psychological symptoms, and side effects or complications from medication therapy were the most common causes of impaired safety, as well as the COVID-19 pandemic.

ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3.

Look-alike medications are vulnerable to wrong route and other use errors. This article examines the potential for mistaken application of ear drops into eyes. Strategies highlighted to reduce this error focus on storage, dispensing, administration, and patient education.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Velasco RAF, Slusser K, Coats H. J Adv Nurs. 2022;78:3083-3100.
Transgender and gender-diverse people may experience poor quality of healthcare due to stigma and discrimination. This systematic review of qualitative studies found that stigma experienced among transgender and gender-diverse patients occurs at the individual (e.g., internalized stigma, marginalization), interpersonal (e.g., verbal abuse from healthcare providers, withholding of care), and structural levels (e.g., gender norms, power imbalances).
WebM&M Case July 8, 2022

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

AORN J. 2022;115:454-457.
This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..
Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.