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 166 Results

How nursing homes’ worst offenses are hidden from the public.

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Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.

To eliminate bias, some seek out doctors of their own race or ethnicity.

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Glicksman E. Washington Post. December 11, 2021.

A successful patient/physician relationship enables care that is specific for the individual, their unique concerns, and distinct lifestyles. This article discusses patient choice in physicians as a strategy to reduce the impact of implicit ethnic bias, while arguing that fundamental change will occur only by reducing racism through system change.

Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction.

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Joseph A. STAT. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.

Confronting Racism in Health Care: Moving from Proclamations to New Practices.

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Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021

Structural racism affects the safety and equity of care delivery. This report summarizes organizational efforts to reduce the impact of systemic racism on patient care, hiring practices, and policy implementation to ensure transparent, equitable and patient-centered care is reliably available to all.

ERs are swamped with seriously ill patients, although many don’t have Covid.

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Wells K. Health Shots. National Public Radio. October 29, 2021.

Emergency department (ED) crowding stemming from treatment delays and deferrals resulting from COVID concerns is an emerging problem. This article discusses how ED crowding affects patients and clinical teams to reduce safety and effectiveness.

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

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US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. 117th Cong. 1^st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

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Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Agency information collection activities: Nursing Home Survey on Patient Safety Culture Database; comment request.

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Agency for Healthcare Quality and Research. Fed Register. September 21, 2021;86:52471-52473.

This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Nursing Home Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?

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Clark C. MedPage Today. September 14, 2021.

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.

How to seek care for non-covid health issues during the pandemic, and why you shouldn’t delay.

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Bever L, Chiu A. Washington Post. September 16, 2021.

Throughout the COVID pandemic, patients have shown reluctance to seek medical care, which contributes to delayed diagnoses and treatments for non-COVID conditions. This news story suggests actions for patients to take to keep themselves safe from harm while accessing care during uncertain times.

Phony diagnoses hide high rates of drugging at nursing homes.

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Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

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Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request.

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Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Curated Libraries

Maternal Safety

September 13, 2021

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.

‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?

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Outcalt C. The Atlantic. August 2021.

Overuse and unnecessary care lead to serious patient harms and a cascade of negative consequences. This story describes the overuse behavior of one surgeon to illustrate influences contributing to the problem.

The Safety of Maternity Services in England.

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Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

The pain was unbearable. So why did doctors turn her away?

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Szalavitz M. Wired Magazine. August 11, 2021.

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

Recognizing Unsafe Care: What It Is and How to Report It.

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Patient Safety Foundation. August 26, 2021.

This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance response, engagement, and reporting efforts of clinicians, patients and families.

Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital?

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Gangopadhyaya A. Washington DC; Urban Institute: July 2021.

Racial inequities have been revealed by the COVID pandemic as a distinct patient safety concern. This report examined racial differences using patient safety indicators to measure hospital-acquired conditions, insurance coverage, and hospital patient population. The results indicate Black patients have reduced safety, that insurance coverage had little influence on safety and hospitals with a higher Black patient population experienced more adverse events that those serving a white patient population.

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