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 310 Results

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.

Error Reduction and Prevention in Surgical Pathology, Second Edition.

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Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.

Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.

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.

Medication Safety in Key Action Areas.

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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.

Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical Thinking in Medicine.

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Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231.

Cognitive biases contribute to diagnostic missteps, delays, and errors. This publication uses case-based illustrations to explore the effect of common cognitive biases (e.g., confirmation, anchoring, and overconfidence) on care. The author suggests feedback, healthy skepticism, and open discussion as tactics to reduce errors stemming from bias in decision-making.

Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.

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Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.

Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.

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.

The Canadian Quality and Patient Safety Framework for Health and Social Services.

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Canadian Patient Safety Institute and Health Standards Organization.

This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.

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.

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