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 1029 Results

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 Fall 2023 hospital safety grade results, documenting a reduction in both patient satisfaction scores and healthcare associated infection rates to pre-pandemic levels, are available.

Addressing Workplace Violence and Creating a Safer Workplace

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Perspective on Safety October 31, 2023

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Health Services Safety Investigations Body.

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Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA.

Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization -- formally known as the Healthcare Safety Investigation Branch or HSIB -- collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

Speak Up Initiative.

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Joint Commission.

The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, how preventive care helps to keep patients healthy and out of the hospital. Each topical package includes infographics, videos, and distribution guidance. Some written materials are available in Spanish.

Personal Health Literacy

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Patient Safety Primer August 30, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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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.

Serious Reportable Events in Massachusetts.

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Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Speak Up [brochures].

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Oakbrook Terrace, IL: Joint Commission. 2002-2023.

A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.

GoodDx.org

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GoodDx.

Effective feedback is an important component of individual, team and organizational learning in order to achieve safe diagnosis. GoodDx.org houses a variety of diagnostic performance feedback resources for use by clinicians, patient safety professionals, educators and patients. The website includes resources targeted towards a multitude of clinical specialties and organizational needs and readiness.

Your Safety in our Hands in Hospital.

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Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.

This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.

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.

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

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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.

The Leapfrog Hospital Survey.

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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.

Patient Safety Awareness Week.

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Institute for Healthcare Improvement.

This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.

Press Play on Safety Conversations.

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Healthcare Excellence Canada. 2022.

After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive communication should a failure or near-miss occur. There are two distinct sections of materials: one for established healthcare professionals, and another for patients, students, and caregivers.

National Healthcare Quality and Disparities Reports.

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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.

How To Create a My Medicines List.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

This tool provides a printable template and step-by-step instructions for patients to create a visual reference for keeping track of medications.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

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