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

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.

PC standards for maternal safety.

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The Joint Commission. R3 Report. August 21, 2019;24:1-6.

Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Provision of Care, Treatment, and Services (PC) standards developed to improve the reliability of maternal care. Actions for improvement include patient risk assessment for conditions at admission and role-specific education for staff and providers who treat maternal patients regarding hemorrhage processes and procedures.

How one health system overcame resistance to a surgical checklist.

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Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.

This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.

Safety in the Prehospital Emergency Medical Services Setting

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Perspective on Safety May 1, 2019

This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.

In Conversation With… Jane Brice, MD, MPH

Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.

Health systems and hospitals in pursuit of high reliability.

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Cheney C. HealthLeaders Media. April 17, 2019.

This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated effort across the system achieved a drop in readmissions and physician burnout. Tactics used to improve reliability include huddles, purposeful redundancy, and leadership engagement.

How one hospital improved patient safety in 10 minutes a day.

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van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.

Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.

Unprofessional workplace conduct...defining and defusing it.

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MacLean L, Coombs C, Breda K. Nursing management. 2016;47:30-4.

Bullying and disruptive conduct hinder teamwork and diminish the safety of care delivery. This article discusses how policies, organizational guidelines, and educational strategies can help nurse leaders develop the skills to address unprofessional behaviors in the workplace.

The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.

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Barker T; Noguez J.

Reporting on the importance of a supportive workplace environment that engages employees in tasks to help ensure safety, this news article discusses root causes for low staff morale in the laboratory environment and suggests tactics to build healthy staff relationships.

'You talking to me?' Docs and feedback.

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Diamond F. Managed care (Langhorne, Pa.). 2013;22:30-2.

Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaking up about concerns and recommends tactics to improve communication.

What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety

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Perspective on Safety September 1, 2013

This piece explores how leaders can promote cultural changes to improve patient safety.

ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction.

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ED management : the monthly update on emergency department management. 2011;23:78-80.

This article reveals how one hospital enhanced emergency care by improving teamwork and implementing a streamlined triage system.

Understanding care transitions as a patient safety issue.

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Butterfield S; Stegel C; Glock S; Tartaglia D.

This article describes a regional collaborative to enhance care transitions of Medicare beneficiaries by improving communication, teamwork, and medication reconciliation.

Are we finally getting serious about medical errors?

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Burns J.

This article explores the challenges to improving patient safety and discusses strategies for reducing medical errors.

Hospitals collaborate to prevent wrong-site surgery.

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Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.

What Do We Know About Emergency Department Safety?

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Perspective on Safety June 1, 2010

Emergency medicine has evolved from a location, with variably trained and experienced providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus on the diagnosis and care of undifferentiated acute problems.(1) The importance of rapid diagnosis and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has made timeliness not simply a determinant of patient satisfaction but also a significant safety and quality concern—delays in care can be deadly.(2) Emergency physicians (EPs) have identified delays caused by crowding fr

In Conversation with…Pat Croskerry, MD, PhD

Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.

Strengthening the core. Middle managers play a vital role in improving safety.

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Federico F, Bonacum D. Healthcare executive. 2010;25:68-70.

This piece outlines steps such as training and senior leader support that can help enhance the role of middle managers in patient safety and quality improvement.

How to Identify and Manage Problem Behaviors

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Perspective on Safety December 1, 2009

The 1999 Institute of Medicine report highlighted the need for health care providers to address the serious concerns raised about the quality and safety of patient care being provided in our health care organizations. Organizations responded by looking at new ways to fix the system, mostly through the introduction of new technologies and system/process redesign. Advances have been made, but there are still significant opportunities for improvement. Is the barrier poor system or process design, or is it related to addressing basic human behaviors?

In Conversation with…Gerald B. Hickson, MD

Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its connection to clinical outcomes and medical malpractice. He is a Professor at the Vanderbilt University School of Medicine, where he is also the Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director of the Vanderbilt Center for Patient and Professional Advocacy, and Director of Clinical Risk and Loss Prevention. We asked him to speak with us about high-risk physicians and malpractice.

Physician leadership is key to creating a safer, more reliable health care system.

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Silbaugh BR, Leider HL. Physician Exec. Sept-Oct 2009;35:12, 14-16.

This article presents three principles that physicians can leverage to support highly reliable, safe care: do no harm, evidence-based practice, and patient-centered teamwork.

Safe intrahospital transport of the non-ICU patient using standardized handoff communication.

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PA-PSRS Patient Safety Advisory; Patient Safety Authority.

This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.

Debriefing for patient safety.

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Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.

This article provides guidelines for effective clinical debriefings and suggests how to position these conversations as learning opportunities.

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