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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 631 Results
Perspective on Safety November 27, 2023

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. 

Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL.

Inspired by the research and leadership of Dr. Robert Wears, this award annually recognizes individuals, teams or organizations that examine the applications of safety science concepts to improve medicine. Nominations for the 2024 award must be submitted by January 2, 2024.

US Department of Health and Human Services. 2023. 

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The most recent session explored the successful application of high reliability concepts at the Veterans Health Administration. There have been five videos in this series of offerings from the Alliance supporting its work to improve safety.

Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.
Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.1 Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

Kathleen Sanford

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Perspective on Safety July 31, 2023

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

Bowman CL, De Gorter R, Zaslow J, et al. BMJ Open Qual. 2023;12:e002264.
Never events are catastrophic adverse events resulting in patient death or significant disability that are largely preventable. This narrative synthesis describes which events organizations most frequently identify as never events, and which are most commonly described as entirely preventable. 125 unique never events were identified, nearly 20% of which were classified as entirely preventable. The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and unintentionally retained objects.

Committee on Unequal Treatment, National Academies. 2023.

Health disparities and unequal care contribute to patient and family harm. This 3-component workshop series explored ethnic and racial disparities in health care. A planned September workshop will revisit the findings from the three sessions.
Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.
Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.
Lainidi O, Jendeby MK, Montgomery A, et al. Front Psychiatry. 2023;14:111579.
Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.
Klemann D, Rijkx M, Mertens H, et al. Healthcare (Basel). 2023;11:1636.
Reducing maternal morbidity and mortality is a global patient safety goal. This systematic review identified three categories of direct and indirect risk factors of maternal safety: delay of care, coordination and management of care, and scarcity of supply, personnel, and knowledge. The risk factors varied between developed and developing countries.
Kelen GD, Kaji AH, Schreyer KE, et al. Ann Emerg Med. 2023;82:336-340.
In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.
Ayre MJ, Lewis PJ, Keers RN. BMC Psychiatry. 2023;23:417.
Medication safety in inpatient and outpatient settings is a major focus of patient safety efforts. This review included 79 studies on epidemiology, etiology, or interventions related to psychiatric medication safety in primary care (e.g., general practice, community pharmacy, long-term care). Most studies focused on older adults and potentially inappropriate prescribing. The authors recommend future research on wider age groups and underrepresented mental health diagnosis, such as attention deficient hyperactivity disorder (ADHD).
Choi JJ, Durning SJ. Diagnosis (Berl). 2023;10:89-95.
Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.
Lee SE, Repsha C, Seo WJ, et al. Nurse Educ Today. 2023;126:105824.
“Horror room” simulations are used to help train medical students to identify patient safety hazards. This systematic review of 16 studies found that “horror room” simulations are more common in Western countries and focus on medication-related or procedure-related incidents. The authors highlight the need for research establishing parameters regarding the ideal size and composition of the team to yield the highest impact on learners.
Jain A, Brooks JR, Alford CC, et al. JAMA Health Forum. 2023;4:e231197.
Algorithms are commonly used to guide clinical decision-making, but concerns have been raised regarding bias due to the use of race-based data. This qualitative analysis examined perspectives of 42 stakeholders (e.g., individuals, representatives from clinical professional societies or payers, etc.) regarding the use of race- and ethnicity-based algorithms in healthcare. Seven themes were identified, highlighting concerns regarding bias, algorithm transparency, lack of standardization regarding how race and social determinants are collected and defined, and the use of a social construct as a proxy in clinical decision-making.

Agency for Healthcare Research and Quality, Rockville, MD. 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.
Zaitoun RA, Said NB, de Tantillo L. BMC Nurs. 2023;22:173.
Nurses play an important role in ensuring patient safety. This systematic review identified 16 studies examining the relationship between nursing competence and safety culture. The researchers identified several gaps in the evidence, including the need for rigorous research measuring the association between safety culture and nursing safety competencies and evaluating the effect of nursing safety competency on safety culture scores.