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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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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...
CDC; Centers for Disease Control and Prevention.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
Vilensky D, MacDonald RD. Prehosp Emerg Care. 2011;15:39-43.
This study analyzed communication errors during call bookings for air medical transport and found both human and process-driven root causes. Examples of major errors identified were commissions of allergies to medications and omissions of intubations from records.
WebM&M Case December 1, 2009
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
WebM&M Case May 1, 2009
An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.
WebM&M Case September 1, 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
WebM&M Case September 1, 2004
An ill physician arrives at the ED for evaluation of shortness of breath. As it is past midnight and he is the only radiologist around, he reads (and misinterprets) his own x-ray.