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 198 Results

Debriefing for Clinical Learning

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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.

Deprescribing as a Patient Safety Strategy

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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.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares errors reported to the ISMP Vaccine Errors Reporting Program and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Health Equity and Maternal Health

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Perspective on Safety October 6, 2021

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.

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.

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.

Geriatric medication reconciliation in the home setting.

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Taylor K. American Nurse J. 2021;16(7):14-17.

Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.

A night in the hospital, from both ends of the stethoscope.

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Ofri D. New York Times. January 5, 2021.

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care.

Using telehealth to revolutionize the speed of making rare disease diagnoses.

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Nothaft W, Moore G, Le Cam Y. STAT. August 27, 2020.

Patients with rare diseases present diagnostic challenges. This article introduces the potential for improvements in diagnosis that telemedicine brings to the process through enabling access to appropriate expertise previously limited by geography.

Missed and delayed diagnoses of non-COVID conditions--collateral harm from a pandemic.

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Carr S. ImproveDx. 2020;7:1-5.

The coronavirus pandemic has disrupted patient care seeking behaviors. This article discusses this phenomenon and its impact on the timing of diagnosis due to fear of contracting COVID-19 or threats resulting from the economic shutdown implemented to reduce spread of the virus.

I can't turn my brain off.

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Hoffman J. New York Times. May 16, 2020.

Health care worker stress is a known contributor to disruptive behavior, error and clinician suicide. This story discusses the impact of the COVID-19 pandemic on psychological strain in clinicians and highlights peer support and other techniques to mitigate its negative effects.

Many COVID-19 survivors will be left traumatized by their ICU experience.

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Jee C. MIT Technology Review. April 22, 2020.

Patient safety can be challenged even after patients are discharged and return home. This story discusses the potential for psychological trauma in patients who survive a COVID-19 ICU stay. Strategies discussed to address the problem include medication, cognitive therapies and personal wellness instruction.

Medical abbreviations that have contradictory or ambiguous meanings.

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Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5.

Multiple organizations have identified using unclear or misleading abbreviations as a threat to patient safety. This article discusses proposed solutions, and provides a rationale for why some solutions may not be feasible.

Prescription drug overload: critics fighting to curb an epidemic of medication side effects.

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Weisman R. Boston Globe. January 13, 2020.

Polypharmacy is a known contributor to adverse drug events in older adults. This story discusses strategies such as brown bag reviews and deprescribing to minimize overprescribing that could contribute to harm.

Patient Safety 101

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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.

Communication Between Clinicians

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Patient Safety Primer September 7, 2019

Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.

Partnering with families and patient advocates: another line of defense in adverse event surveillance.

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ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.

Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.

A mismatch made in America.

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Butcher L. Managed Care. June 2019;28:37-39.

Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.

Hospitals look to computers to predict patient emergencies before they happen.

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Ross C. STAT. May 13, 2019.

Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.

Perioperative medication errors: uncovering risk from behind the drapes.

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Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2018;15(4):1-17.

The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

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