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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 1372 Results
Institute for Safe Medication Practices. October 4-5, 2023, 10:45 AM - 7:45 PM (eastern).
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Armstrong Institute for Patient Safety and Quality, Baltimore, MD. October 3-4, 2023.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Betsy Lehman Center for Patient Safety. September 29, 2023, 10:00 AM - 12:30 PM (eastern).

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This annual hybrid session explores elements of effective discussions after an adverse event through case simulation and dialogue. The site also includes an archive of videos and materials from previous forums.
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Sanfilippo JS, Kettering C, Smith SR. Clin Obstet Gynecol. 2023;66:293-297.
Effective apology for medical mistakes is a cornerstone for healing and improvement. This piece discusses the impact sincere and complete apologies may have on legal resolutions of patient harm. They discuss the current presence of apology laws at the state level and the limited role they play in protecting clinicians who err and apologize in a court of law.
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Institute for Healthcare Improvement. September 13 - November 7, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
Folcarelli P, Hoffman J, Janes M, et al. J Healthc Risk Manag. 2023;43:26-31.
Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.
Krevat S, Samuel S, Boxley C, et al. JAMA Netw Open. 2023;6:e238399.
The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19:211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims with at least one diagnostic error were analyzed. No singular factor was identified; instead multiple contributing factors were implicated along the diagnostic pathway.
WebM&M Case March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.

Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

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.
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Thomas AD, Pandit C, Krevat S. J Patient Saf. 2023;19:67-70.
Previous research has identified disparities in adverse events and patient safety risks for Black patients compared to White patients. In this study, researchers used a large healthcare system’s malpractice database to examine racial differences in malpractice lawsuits. Although there were no significant race differences in lawsuits, findings suggest that employees are more likely to identify potential malpractice events for White patients compared to Black patients.
Hyman DA, Lerner J, Magid DJ, et al. JAMA Health Forum. 2023;4:e225436.
Prior research has shown that physicians with more than three paid medical malpractice claims are at increased risk of another claim in the next two years. This study assessed the risk of additional claims after just one paid malpractice claim, whether public disclosure of claims increased the risk, and whether the risk changes over time. The authors also compare actual claims rates to simulated rates if malpractice claims were “random” events unrelated to prior claims.
Society to Improve Diagnosis in Medicine. Cleveland, Ohio, October 8-11, 2023.
Diagnostic error reduction continues to gain momentum in the research and frontline patient safety communities. This in-person conference will focus on the theme, "The Future of Diagnosis: Achieving Excellence and Equity." 
Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.
Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.