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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 21 Results

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.
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...

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.  

Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.

Tracking problems with health information technology (Health IT) is an important strategy to drive improvement. This report outlines general health IT and decision support actions to inform action, and discusses the role that regulation and accreditation have for driving improvement.
Lightner NJ, Kalra J, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030204501.
Human-centered processes, technology, and equipment design affect the safety of care. This book provides conference proceedings that explore the application of human factors and ergonomics expertise in six areas of health care (patient safety, health information systems, worker safety, clinician decision support, medical device development, and care of older patients) to improve safety.
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.
Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publishing; 2019. ISBN: 9783030169152.
Challenges associated with electronic health record design and implementation contribute to interruptions, workarounds, and information overload. This book explores topics relevant to workflow disruptions that can degrade safe practice. The chapters review strategies such as data analysis techniques and human factors engineering to generate improvements.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
Inconsistent checking for and consideration of drug allergy alerts can diminish the safety of prescribing. This report from a multistakeholder work group provides evidence-based safe practices and recommendations for improvement, including standardizing documentation practices, actionable decision support, monitoring of alert effectiveness, and patient engagement.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.

Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508.

Information technology is prevalent in health care and is associated with both optimized processes and unintended consequences. This publication is a compilation of papers from an international conference that explored the potential of health information technology and the research needed to achieve success. Topics covered include usability, implementation, interoperability, and policy.
Horsham, PA: Institute for Safe Medication Practices; January 2019.
Inaccurate or incomplete data in electronic health records can limit the effectiveness of health information technology. This guideline focuses on improvements in how medication information is formatted to support safe medication delivery. Recommended approaches include avoidance of error-prone abbreviations, use of Tall Man lettering, and required use of metric measurements to reduce risks in electronic health records, barcoding systems, smart infusion devices, and other information technologies.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC: Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
This report evaluates the implementation of a quality improvement initiative designed to characterize, track, and mitigate adverse events related to health information technology (IT). Investigators sought to determine challenges to engaging in identifying and addressing safety risks related to health IT in 11 health care organizations, and this publication outlines experiences and lessons learned from participating institutions. The authors call for greater awareness of safety risks related to health IT, better cooperation between risk management and health IT departments, identification of safety measures for health IT, incentives for health IT developers and vendors to improve health IT safety, and increased investment in risk management, health IT, and safety in ambulatory settings. The recommendations in this report serve as a blueprint for future practice and policy efforts to augment safety in the era of electronic health records.
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.

Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.  

This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
This report from the Department of Health and Human Services (HHS) describes a plan to bolster implementation of health information technology (IT) and reduce risks associated with its use. Building on recommendations of the Institute of Medicine report, Health IT and Patient Safety, the plan includes specific action items for HHS organizations and the private sector to augment health IT safety. Responsibilities will be shared across a number of HHS organizations: the Office of the National Coordinator (ONC), the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services. Goals involve making it easier for clinicians to report health IT–related incidents and hazards, encouraging reporting to Patient Safety Organizations, supporting the use of standardized forms in hospital incident reporting systems, and training surveyors to identify safe and unsafe practices associated with health IT. The Joint Commission has also contracted with ONC to better detect and address potential health IT–related safety issues across health care settings.
Rogers EM. New York NY: Free Press; 2005.
Those who seek to improve the quality and safety of health care would be well served by a deeper understanding of how innovations spread through systems. Rogers first described the diffusion of innovations in a seminal study in 1962. The 5th edition expands on his classic discussions of adopter categories (innovator, early adopter, early majority, late majority, and laggards) and how these personality types influence the spread of new ideas. The updated text includes new insights related to public health, communications, and use of the Internet.