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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 - 6 of 6 Results

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.

Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

Challenges to effective clinical reasoning reduce diagnostic accuracy. This special issue provides background for a new approach to clinical reasoning: situativity. The articles explore the four complementary facets of the concept -- situated cognition; distributed cognition; embodied cognition; and ecological psychology – and describes how situativity can enhance diagnosis through a holistic approach to education, assessment, and research.    
Chung L, Kumar S, Oldfield J, et al. J Patient Saf. 2022;18:e115-e123.
This systematic review investigated the use of anatomical side markers (ASM), which are used in radiology to identify the correct anatomical side and prevent confusion. The seven studies included demonstrated that use of ASMs is common, but the literature documented some barriers to use, such as risk of obscuring essential anatomical parts.
National Quality Forum
This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.
Radiology ES of, Societies EF of R. Insights Imaging. 2019;10:45.
Numerous factors affect safe imaging practice, including potential harms associated with radiation, staffing demands, and patient physical and psychological well-being. This policy statement provides multidisciplinary insights on safety themes in radiology that go beyond the core concern of inappropriate radiation exposure. The authors recommend tactics to reduce the risks related to data protection, service environment, teamwork, burnout, and training.
Perspective on Safety January 1, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.