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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 40 Results
Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. The 2023 survey session opens April 1, 2023.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Perspective on Safety April 27, 2022

This piece discusses the role that media plays in affecting patient safety.

This piece discusses the role that media plays in affecting patient safety.

Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. He serves on the Board of Directors for Project Patient Care, and earlier in his career he was a healthcare reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize. We spoke with him about how patient safety efforts are shaped by the media and how the role of media has changed since our original discussion on the role of media in patient safety (published in October of 2009 (;

Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
150 Kent Street, Suite 200, Ottawa, Ontario, K1P 0E4 Canada.
This new organization fosters collaboration between governments and stakeholders in developing patient safety initiatives. This Web site provides tools for health care professionals and patients. It was formed in March 2021 through the merging of the Canadian Foundation for Healthcare Improvement and the Canadian Patient Safety Institute.
Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. The PSNet Human Factors Engineering primer expands on these concepts.  
Mazer BL, Nabhan C. J Gen Intern Med. 2019;34:2264-2267.
Published estimates on the number preventable medical errors have generated some controversy. This perspective discusses the inaccuracy of these estimates, the role of the media in disseminating them, and how physicians can bring context to conversations on the prevalence of medical error.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures. Highlighting concerns at one medical center that were found to contribute to opportunities for waste, fraud, and poor health care delivery, this report by the Office of Inspector General outlines 40 recommendations to address deficiencies.
Joint Commission.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2014 honorees are Mark L. Graber, MD, the American College of Surgeons National Surgical Quality Improvement Program, and North Shore-LIJ Health System in New York. The awards were presented at the National Quality Forum's annual conference on March 23, 2015, in Washington, DC.
Joint Commission. January 27, 2014.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2013 honorees are Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health, from Minnesota; Anthem Blue Cross, National Health Foundation, Hospital Association of Southern California, Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California, from California; Vidant Health, of North Carolina; and Gail L. Warden, in Michigan. The awards were presented at the National Quality Forum's Annual Conference on February 13, 2014, in Washington, DC.
Division of Licensing and Regulatory Services; Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Columbia, MO: Association of Health Care Journalists.
This Web site provides access to federal hospital inspection reports that detail deficiencies cited from complaint inspections at acute care and critical access hospitals.
International Society for Quality in Health Care; ISQua.
This Web site provides access to communities of practice, online learning activities, and discussions exploring safety and quality.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.
Tennessee Center for Patient Safety.
This Web site summarizes patient safety improvement efforts in Tennessee, shares information on their patient safety organization activities and a calendar of training opportunities.