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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 42 Results
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.

Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.1

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.
Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Patient Safety Innovation May 16, 2022

Medical residents, alongside interns, nurses and attending physicians, are uniquely positioned to identify safety concerns because they are on the front lines of patient care.1 Residents can bring a fresh perspective that is informed by their cross-department training experiences.1,2 As a tool to leverage resident potential and improve reporting of safety events, some evidence supports the use of resident-led training and hands-on activities.3,4 Yet, while there are many studies on patient

Patient Safety Innovation May 16, 2022

Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading to hospital readmission in the United States.1,2 To improve medication-related safety and reduce hospital readmissions, the Memphis Veterans Affairs Medical Center (VAMC) started a transitional care clinic (TCC) led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after they are discharged from the hospital or emergency department (ED). CPSs are independent mi

Patient Safety Innovation April 7, 2022

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.1 Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.2 Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.2

Patient Safety Innovation April 7, 2022

An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).1 Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital.

Patient Safety Innovation April 7, 2022

Obtaining a best possible medication history is the cornerstone of medication reconciliation but can be resource-intensive. This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. 

Patient Safety Innovation February 23, 2022

With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy.

Patient Safety Innovation January 26, 2022

The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.

Patient Safety Innovation January 7, 2022

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.1 Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice