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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 745 Results
Brooks K, Landeg O, Kovats S, et al. BMJ Open. 2023;13:e068298.
National and organizational emergency response plans lay out policies and procedures to prepare for and respond to unexpected natural disasters and other public health emergencies. This study examines clinician and non-clinician perspectives on safety during the 2019 record-breaking heatwave in the United Kingdom. Clinicians reported not being aware of national heatwave preparedness and response plans, and several challenges were mentioned, including insufficient cooling equipment. 
Ortega RP. Science. 2023;379:870-873.
Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and patient/physician communication. This article highlights efforts to understand implicit biases in health care professionals. It discusses initiatives and tools in development to reduce the presence of unconscious bias in health care.
Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.

Plymouth Meeting, PA: ECRI; March 2023.

The global COVID-19 pandemic continues to exacerbate weaknesses in care that can contribute to harm. ECRI presents the top ten patient concerns for 2023, including pediatric mental health care, workplace violence, care coordination, and patient medication list mistakes.  

Food and Drug Administration. February 23. 2023.

Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence. This series of case studies drawn from reports submitted to the Food and Drug Administration illustrates a variety of misconnection scenarios to demonstrate situations that have a range of potential for patient harm.

Reed J. BBC. February 27, 2023.

Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing investigation in the British National Health Service to examine factors in ambulance services that minimize its safety and effectiveness. Clinicians interviewed revealed serious problems with the work cultures.
McCarty DB. Adv Neonatal Care. 2023;23:31-39.
Racism is increasingly seen as a major contributor to poor maternal care and adverse outcomes. This article summarizes racial health disparities impacting patients in the neonatal intensive care unit (NICU) and interventions to reduce racial bias in the NICU.

Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.
Kobeissi MM, Hickey JV. Jt Comm J Qual Patient Saf. 2023;49:213-222.
The COVID-19 pandemic led to the rapid expansion and adoption of telehealth. The authors of this article discuss how to leverage the increased use of telehealth and propose a new organizational telehealth program model to help organizations develop and sustain safe, equitable, and high-quality telehealth programs.
Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;Epub Jan 30.
Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.
Freund O, Azolai L, Sror N, et al. J Hosp Med. 2023;Epub Feb 13.
The COVID-19 pandemic led to unprecedented numbers of patients seen in the emergency department (ED), some who had COVID-19, some who had a different diagnosis, and some who had both. This study analyzes patients who presented to the ED with COVID-19 and signs of another diagnosis that was missed. Approximately one-third of patients with a second concurrent diagnosis experienced a diagnostic delay. Factors that may have influenced the missed diagnosis include ED overcrowding and anchoring heuristics.
Giardina TD, Woodard LCD, Singh H. J Gen Intern Med. 2023;Epub Jan 5.
Variations in diagnostic process application reduce the safety of care. This commentary discusses how clinician engagement, community partnerships, and connected care (e.g., telehealth) should interface to improve diagnosis for patients impacted by disparities and implicit bias.
Danielson KK, Rydzon B, Nicosia M, et al. JAMA Netw Open. 2023;6:e2253275.
Patients with diabetes may not be aware of their condition and therefore may not seek timely care. In this pilot study, patients presenting to the emergency department at risk of type 2 diabetes were flagged by the electronic health record. Clinicians could then add hemoglobin A1c (HbA1c) to scheduled blood draws. Of the patients with elevated HbA1c levels contacted by study staff, three-quarters were not aware of a previous diabetes diagnosis.
Jafri FN, Yang CJ, Kumar A, et al. Simul Healthc. 2023;18:16-23.
In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.
Engel FD, da Fonseca GGP, Cechinel-Peiter C, et al. J Patient Saf. 2023;19:e46-e52.
Due to the infectious and deadly nature of COVID-19, heath care facilities were forced to change many of their person-centered policies, including restriction on visits from family and friends. This review highlights factors that impacted hospitalized patients during COVID-19. Thirty-two studies were identified and classified into three main factors: concern about the patient’s well-being during hospitalization, communication and interaction between patients, families, and care team, and the impact on the health care organization.
Jeffers NK, Berger BO, Marea CX, et al. Soc Sci Med. 2023;317:115622.
Structural racism contributes to high rates of severe maternal morbidity (SMM) experienced by Black patients. This study investigated specific measures of structural racism (incarceration inequality and racialized economic segregation) on Black SMM. In this sample of births from 2008-2011, racialized economic segregation was associated with SMM for black patients; however, incarceration inequality was not.