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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 324 Results

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.

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.

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.
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.
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.
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.

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.
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.
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.
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.

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.
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.
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. 

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.
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.

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.

Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232.

Care coordination failures reduce the effectiveness of communication, information transfer, and patient monitoring to the determent of safety. This report examines the current state of interfacility transfers in 45 veteran facilities to find that, while process requirements were basically met, improvements could be made to medication list transfer, nursing communication, and general service evaluation.
Nijor S, Rallis G, Lad N, et al. J Patient Saf. 2022;18:e999-e1003.
Usability issues related to electronic health record (EHR) use among clinicians can contribute to burnout and threaten patient safety. This literature review outlines how EHR usability issues, such as information overload, can lead to errors and threaten patient safety. The authors suggest that future research explore methods to mitigate EHR overload-related errors, including the role of EHR usability.

Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.

Misuse of insulin pens contributes to never events associated with diabetic medication therapy in hospitalized patients. This investigation of an injurious insulin extraction workaround culminated in recommendations to improve insulin administration safety including the explicit use of pen devices to administer U-500 insulin.
Hoffman S. J Med Regulation. 2022;108:19-28.
Patient safety advocates have called for cognitive testing of aging clinicians and some health systems have attempted instituting such policies as part of their recredentialing program. This commentary calls for state medical boards to adopt cognitive testing as part of the recredentialling process within the confines of legal boundaries.