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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 89 Results
Okemos, MI: Michigan Health & Hospital Association.
This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. This most current year's achievements include submission of 134 root cause analysis to the state patient safety organization reporting system. Areas of focus for improvement work included obstetrical safety, workplace safety, and COVID-19 and infection control.
Curated Libraries
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, care standardization,teamwork, unit-based safety initiatives, and...
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Boston, MA: Institute for Healthcare Improvement; 2018.
The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence assessment to provide recommendations to improve the safety of home-based care. The document outlines five guiding principles to enhance safety of home care, which include a focus on person-centered care, safety culture, learning and improvement systems, team-based and coordinated care provision, and incentive models.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.
Philadelphia, PA: American College of Physicians; 2017.
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. This position paper highlights seven recommendations to address patient safety challenges in the ambulatory environment, including enhancing patient health literacy, utilizing team-based care models, and establishing a national effort to reduce patient harm across all settings of health care.
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017.
Advocates for improving diagnosis emphasize the role of the patient as key to success. This report examines factors to consider when designing interventions to strengthen patient participation in the diagnostic process. Recommendations to enhance relationships with patients to reduce diagnostic error focus on managing misperceptions that can affect decision-making and communication.
Chicago, IL: American Hospital Association; 2017.
The opioid epidemic is a challenge to patient safety and public health. This report reviews tools to help health care systems target eight areas of focus that have potential to reduce the impact of opioid misuse, including improving prescribing practices, collaborating with communities, and educating patients.
Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017. ISBN 9781947103108.
Morbidity and mortality from opioid medications constitutes a patient safety problem. This National Academy of Medicine report explores the role of physicians in preventing and treating opioid misuse. The report highlights the increasing rate of opioid prescriptions in parallel with rising numbers of opioid overdose deaths and recommends adherence to clinical guidelines on opioid use, specifically the 2016 CDC guideline. The authors call for improved access to opioid prescription and dispensing data and more stringent regulation of opioid medications. They provide detailed recommendations for clinicians to prescribe opioids more safely, including the use of prescription drug monitoring programs, coprescription of naloxone, and engaging with community resources to identify and treat opioid use disorder. A recent PSNet perspective discussed opioid overdoses as a patient safety problem.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.
Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.
The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.