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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 56 Results
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Curated Libraries
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January 14, 2022
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Patient Safety Primer
January 11, 2022
Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.
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Patient Safety Primer
November 18, 2021
Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.
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Patient Safety Primer
October 27, 2021
Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.
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September 13, 2021
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Patient Safety Primer
April 21, 2021
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
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Patient Safety Primer
April 1, 2021
An essential aspect of preventing medical errors and improving patient safety is using data effectively to understand, track and communicate performance on patient safety metrics. This primer provides an overview of visual tools – histograms, scatter plots, run charts and control charts – hospitals and health systems can leverage to track patient safety data.
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Patient Safety Primer
March 12, 2021
Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.
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Patient Safety Primer
July 30, 2020
This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.
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Patient Safety Primer
March 25, 2020
Discharge planning is an essential part of transitions of care, during which patients are often at a higher risk for adverse events and harm. It is important for all healthcare providers to identify risk factors prior to transitioning patients and put plans in place as part of the discharge plan to mitigate harm. Effective discharge planning between the discharging and accepting healthcare teams can help reduce adverse events.
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Patient Safety Primer
January 29, 2020
Communication failures among healthcare personnel are significant contributors to medical errors and patient harm.
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Patient Safety Primer
September 7, 2019
Clinical decision support systems provide information or recommendations to help clinicians make safe and evidence-based decisions. The use and sophistication of these systems have grown markedly over the past decade, due to widespread implementation of electronic health records and advances in clinical informatics.
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Patient Safety Primer
September 7, 2019
Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.
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Patient Safety Primer
September 7, 2019
Over the past decade, the opioid epidemic has taken the lives of tens of thousands of patients. Much of the epidemic can be ascribed to inappropriate prescribing of opioids, despite knowledge of the safety risks they pose. Current efforts to improve opioid safety have primarily focused on reducing opioid prescribing.
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Patient Safety Primer
September 7, 2019
Pharmacists in all settings play a crucial role in medication safety.
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Patient Safety Primer
September 7, 2019
Infections after surgery are common and frequently lead to hospital readmission and other adverse consequences for patients. Recent programs, including several led by the Agency for Healthcare Research and Quality, have demonstrated how hospitals can successfully prevent these infections.
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Patient Safety Primer
September 7, 2019
Most safety improvement efforts justifiably emphasize system performance. A clinician's individual skill level is an important component of the care delivery system that can influence patient safety—both independently and in conjunction with other system components. Emerging evidence examines assessment, monitoring, and improvement of clinicians' competence as a means of addressing this unique component and ensuring patient safety.
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Patient Safety Primer
September 7, 2019
The widespread implementation of electronic health records has caused a sea change in health care and in medical practice. The digitization of health care data has had some positive effects on patient safety, but it has also created new patient safety concerns.
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Patient Safety Primer
September 7, 2019
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
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Patient Safety Primer
September 7, 2019
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
