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 328 Results

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

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Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.

Gaps in care for psychologically vulnerable patients can result in harm to family members and self-harm. This report examines organizational failures in responding to staff and clinical leaders’ concerns regarding access, triage, and care continuity for mental health patients. Recommendations for improvement include same-day access to appropriate specialty care, medication management, and risk documentation.

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.

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Brummell Z, Braun D, Hussein Z, et al. BMJ Open Qual. 2023;12:e002092.

Reporting adverse events and lessons learned can help improve patient safety beyond the original impacted facility, but low-quality reports can hinder learning. This study describes the quality of reports submitted during the first three years of England’s mandatory Learning from Deaths (LfD) program. While up to half of National Health Service (NHS) hospital trusts submitted data for all six regulatory statutes, a small minority did not submit any data. Three years in, the identification, reporting, and investigation of deaths has improved, but evidence of improved patient safety is still lacking.

On Patient Safety.

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Tingle J. Br J Nurs. 2001-2023.

This series of commentaries discusses a wide range of policy, legal, and operational topics related to patient safety in the British Health system, such as artificial intelligence, patient compensation for harm, and curricula.

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

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Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.

During in-flight emergencies, sometimes airlines’ medical kits fall short.

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Ramachandran V. Kaiser Health News. January 6, 2023.

Inadequate equipment and personnel training degrade the reliability of individuals to provide safe care in an emergency. This article discusses inconsistent preparedness throughout commercial aviation to support care during an in-flight medical situation; it suggests federal oversight of medical kits may help to ensure their completeness and improve the potential for safety should care be required.

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

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Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments is January 26, 2023.

National Patient Safety Board Act of 2022.

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HR 9377, 117th Cong, 2d Sess (2022).

The need for a national government-led patient safety effort has long been advocated for. This legislation outlines the structure of a federal agency to provide support for patient safety data collection, national incident analysis, and recommendation development.

Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act.

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Apathy NC, Howe JL, Krevat SA, et al. JAMA Health Forum. 2022;3:e223872.

Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

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Childs E, Tano CA, Mikosz CA, et al. Jt Comm J Qual Patient Saf. 2023;49:26-33.

In response to the increase in opioid deaths, the Centers for Disease Control and Prevention (CDC) released the Guidelines for Prescribing Opioids for Chronic Pain in 2016, with an update released in 2022. This study reports on the CDC Opioid QI Collaborative which was launched to identify successful evidence-based strategies for implementing the guidelines. The challenges and strategies described in the publication can be used by health systems to accelerate implementation of the guidelines.

ASHP Guidelines on Preventing Diversion of Controlled Substances.

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Clark J, Fera T, Fortier CR, et al. Am J Health Syst Pharm. 2022;79:2279-2306.

Drug diversion is a system issue that has the potential to disrupt patient access to safe, reliable medications and result in harm. These guidelines offer a structured approach for organizations to develop and implement drug diversion prevention efforts. The strategies submitted focus on foundational, organizational, and individual prevention actions that target risk points across the medication use process such as storage, prescribing, and waste disposal.

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

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Washington DC; Office of Senator Mark Warner: November 25, 2022.

There is lack of consensus concerning the need for increased system and policy attention on cybersecurity challenges as a threat to patient safety. The report suggests modifications within the federal government infrastructure to increase attention to cybersecurity as a safety issue, public/private partnership opportunities, and policy development to reduce the potential for cyberattacks that impact care delivery.

Patient safety culture in assisted living: staff perceptions and association with state regulations.

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Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.

Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.

Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.

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Ostrovsky D, Novack V, Smulowitz PB, et al. JAMA Network Open. 2022;5:e2241461.

Previous research has found that fear of malpractice can influence medical decision-making. This survey of emergency department attending physicians and advanced practice clinicians in Massachusetts found that fear of harming patients played a larger role in medical decision-making than fear of legal action.

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

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Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.

Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.

Medical error and vulnerable communities.

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Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.

A new category of "never events"-ending harmful hospital policies.

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Chokshi DA, Beckman AL. JAMA Health Forum. 2022;3:e224703.

Never events serve as triggers to motivate substantive improvement in health care organizations should they occur. This commentary expands the concept to include organizational policies that harm patients and reduce care quality. The authors highlight five strategies to be considered as never events that are particularly problematic for patients: debt collection, inadequate community support, lack of cost transparency, poor staff salaries, and racially-segregated care provision.

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders.

The National Healthcare System Action Alliance to Advance Patient Safety.

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US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

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Sachs JD, Karim SSA, Aknin L, et al. Lancet. 2022;400:1224-1280.

COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

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Washington, DC: United States Government Accountability Office; Publication GAO-22-105133. September 14, 2022.

COVID-19 generated unprecedented challenges for the nursing home industry, revealing and amplifying process, staffing, trust, and infection control weaknesses to the detriment of care. This report analyzed current infection protection actions in long-term care. A primary improvement conclusion drawn from the examination is to strengthen the role of infection control professionals.

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