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 1109 Results

Ambulatory Surgery Center Survey on Patient Safety Culture.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2020.

Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.

Preventing Workplace Violence.

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National Action Alliance. June 27, 2023. 2:00- 3:00 PM (eastern)

Violence in the health care environment detracts from staff and clinician ability to provide safe care. Sponsored by the Centers for Disease Control and Prevention, this webinar will discuss the importance of violence prevention.

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.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Burnout in Primary Care: Assessing and Addressing It in Your Practice.

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Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025.

Burnout reduction in primary care is critical to patient safety. This resource is designed to help practices assess the causes of burnout in primary care and implement strategies to promote well-being. Suggested areas of focus include the reduction of documentation tasks, use of huddles and peer support.

National Action Alliance to Advance Patient Safety Webinar Series.

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Health and Human Services. June 27, 2023. 2:00-3:00pm (eastern).

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 session will explore the importance of preventing workplace violence in healthcare settings. This is the second in a series of offerings from the Alliance supporting its work to improve safety.

Hospital Safety Grade.

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Leapfrog Group

Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Spring 2023 hospital safety grade results, documenting the impact of COVID-19 on patient satisfaction and healthcare associated infection, are available.

Surveys on Patient Safety Culture.

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Rockville MD: Agency for Healthcare Research and Quality; 2020.

Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

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Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.

National Prescription Drug Take Back Day.

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Drug Enforcement Administration. April 22, 2023.

Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This semi-annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.

National Healthcare Quality and Disparities Report Chartbook on Patient Safety.

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Rockville, MD: Agency for Healthcare Research and Quality; March 2023. AHRQ Pub. No. 23-0032.

The Network of Patient Safety Databases (NPSD) serves a central role in understanding the current state of care as tracked by patient safety measures. The 2023 Chartbook offers an overview of nonidentifiable, aggregated patient safety event, and near-miss information, voluntarily reported to data collection initiatives across the United States between 2000 and 2020. The Chartbook includes a summary of trends, disparities findings, and figures illustrating select patient safety measures.

Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed).

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PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights a funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement.

Curated Libraries

Value and Patient Safety

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.

Examples of Medical Device Misconnections.

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Food and Drug Administration. February 23. 2023.

Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence. This series of case studies drawn from reports submitted to the Food and Drug Administration illustrates a variety of misconnection scenarios to demonstrate situations that have a range of potential for patient harm.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; February 8, 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 is April 18, 2023.

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.

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

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Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Pub. No.22(23)-0065-1.

Research has shown that involving patients, their families and caregivers, in the planning, delivery, and evaluation of their healthcare can improve safety and quality. This collection of AHRQ-funded work includes summaries of 53 projects since 2000 that contributed to environments in which patients, families, and healthcare professionals work together to improve the quality and safety of care. Efforts highlighted include those involving patients and families in activities designed to report and ultimately prevent medical errors and near misses.

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

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Agency for Healthcare Research and Quality. January 24, 2023.

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session introduced the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey were shared.

AHRQ Safety Program for MRSA Prevention.

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Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023.

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. This project will support the implementation of targeted hospital-acquired infection prevention initiatives building on the Comprehensive Unit-based Safety Program (CUSP) concept. The cohort that is focused on long-term care is currently recruiting participants.

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.

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