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 264 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.

How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years.

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Fortis B, Bell L. Pro Publica. September 12, 2023.

Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.

Covering Health: Patient Safety.

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HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2023.

The role media plays in raising awareness of patient safety issues in a timely and appropriate manner is consequential. This series instructs writers to communicate on medical error and quality topics in a high-quality professional style with discernment of the content being reported. Series contributions include discussions on medical error statistics and outpatient surgery rankings.

Unstoppable: this doctor has been investigated at every level of government. How is he still practicing?

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Waldman A. ProPublica. August 9, 2023

Systemic failures can enable poor practice to perpetuate without regard to safety. This news feature reports on systemic flaws that enabled a vascular surgeon with questionable business and clinical skills to continue to practice after numerous regulatory organizations investigated his clinics, and after patients reported harm.

The Retrievals.

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Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.

‘Medical errors are the third leading cause of death’ and other statistics you should question.

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Jaklevic MC. HealthJournalism.org. July 27, 2023.

Published rates of medical errors continue to draw attention to gaps in care that demonstrate the need for continued effort toward development and implementation of system-focused safety solutions. This article discusses the importance of representing error statistics responsibly and offers recommendations to ensure accurate representations of the challenges facing safe care delivery.

Inside the preventable deaths that happened within a prominent transplant center.

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Blau M. ProPublica. June 14, 2023.

Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.

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.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Saving Moms.

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Boswell B. KCET: April 2023.

Increasing attention is being placed on addressing inequities in maternal health care. This video shares stories of mothers experiencing harm during pregnancy and steps being taken to minimize the impact of implicit biases and lack of access to care to generate improvement.

Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt.

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Hopkins E, Kohler J. ProPublica. April 3, 2023.

Systemic bureaucracy can contribute to process gaps that result in needless complexities and failure. This news story outlines how inefficiencies in disciplinary investigations can enable clinicians with poor and questionable care records to practice over time.

Crisis in the Lakeshore Hospital ER.

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Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

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Westwood R. Kaiser Health News. January 12, 2023.

Lack of access to obstetric care impedes safe treatment for mothers. This story describes challenges one mother experienced in finding care during a miscarriage due to abortion policies and the steps she and her family took to manage her condition.

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.

ER doctors misdiagnose patients with unusual symptoms.

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Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

From heart disease to IUDs: how doctors dismiss women’s pain.

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Bever L. Washington Post. December 13, 2022.

Gender and racial bias contributes to inadequate and delayed care. This story focuses on women who have experienced harm due to their pain concerns being marginalized or dismissed.

Jake Tapper shares harrowing story of daughter's near-fatal misdiagnosis.

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CNN. December 15, 2022.

Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’s misdiagnosed appendicitis and discusses factors associated with the error including lack of concern by staff for her pain and premature closure.

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

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Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Walgreens will stop judging its pharmacy staffers by how fast they work.

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Kaplan A. NBC News. October 27, 2022.

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.

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