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 326 Results

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

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Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

Healthcare leaders' and elected politicians' approach to support-systems and requirements for complying with quality and safety regulation in nursing homes - a case study.

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Magerøy MR, Braut GS, Macrae C, et al. BMC Health Serv Res. 2023;23:880.

Ensuring staff have a safe work environment and patients receive safe care are separate but complementary goals. This study describes how elected politicians and healthcare leaders balance workplace safety regulations and patient quality and safety goals in long-term care facilities. Tensions between the groups were identified (e.g., where leaders see flexibility, elected leaders see vagueness). Study themes include creating and improving channels for communication, and clear delineation of roles and responsibilities.

A Transformational Effort on Patient Safety.

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Subgroup on Patient Safety. Washington DC: President’s Council of Advisors on Science and Technology; September 2023.

The President’s Council of Advisors on Science and Technology brings together topic experts to summarize important issues for the consideration of the President of the United States. This report introduces the persistent problem of unsafe care and recommends a federal leadership entity, application of evidence-based solutions, true patient partnership and research funding as avenues to achieve stable improvement.

Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence.

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Shaw L, Lawal HM, Briscoe S, et al. Health Expect. 2023;Epub Jul 14.

Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

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Allen A. KFF Health News. June 21, 2023.

A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

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118th Cong (2023-2024).

Nurse staffing and patient care outcomes are linked, yet variation exists in nursing coverage throughout the United States. This submitted bill aims to legislate a national minimum nurse-to-patient staffing ratio as a strategy to enhance safety and quality improvement.

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.

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Barger LK, Weaver MD, Sullivan JP, et al. BMJ Med. 2023;2:e000320.

The Accreditation Council for Graduate Medical Education (ACGME) in the United States limits resident physicians' workweek to 80 hours. Several studies have investigated the association between first year residents (i.e., interns, PGY1), worked hours and patient safety. This study includes residents beyond the first year (i.e., PGY2+). Nearly 5,000 PGY2+ residents reported the number of hours worked, patient safety outcomes, and resident health and outcomes. Working more than 60 hours in a week significantly increased the risk of a medical error resulting in patient death. The authors suggest weekly workweek limits should be significantly reduced, such as they are in the United Kingdom.

Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation.

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Wiig S, Macrae C, Frich J, et al. Front Public Health. 2023;11:1087268.

Patient safety incident investigations are important tools for identifying failures and facilitators of patient harm. This article provides an overview of the regulatory bodies in Norway that are involved in investigating adverse events and how the language used during these investigative activities can support or impede the process.

Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.

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Donovan-Smith O. Spokesman Review. March 15, 2023.

Implementations of electronic health record (EHR) systems are complex efforts that have the potential for injury, should failure occur. This article discusses the Veterans Affairs EHR implementation project that is associated with six incidents of patient harm and calls for improvement at the federal level.

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.

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.

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 has passed.

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 S, 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.

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.

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