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 26 Results

AHRQ announces interest in research on digital healthcare safety.

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Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.

Malnutrition in Hospitalized Adults: A Systematic Review.

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Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021. AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.

The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science.

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Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.

Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities (R18).

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Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267.

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.

Center for Innovations in Quality, Effectiveness and Safety. IQuESt!

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Houston, TX: Baylor College of Medicine.

This Center represents a partnership with the Veterans Affairs Health Services Research & Development Center of Innovation to enhance researchers' skills through active participation in diagnostic safety research and policy development. The goals of the program include a focus on behavioral health interventions and measurement.

Using Innovative Digital Healthcare Solutions to Improve Quality at the Point of Care (R21/R33 - Clinical Trial Optional).

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Rockville, MD: Agency for Healthcare Research and Quality. February 9, 2021. PA-21-164.

Digital strategies hold promise for improving point-of-care efficiency, communication, and safety. This funding opportunity will support research exploring how digital technology can be designed and implemented to improve the quality of healthcare services delivery at the point of care. Areas of interest include the use of patient-facing technologies, development of advanced analytics, and improvements in point-of-care clinical decision making.

Improving Diagnosis in Medicine Act of 2020.

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116^th Congress 2d session. December 10, 2020.

The strengthening of diagnostic error research and processes can strategically ensure lasting diagnostic improvement. The ‘‘Improving Diagnosis in Medicine Act of 2020’’ outlines characteristics of a proposed Federal program to enhance agency cooperation and coordination to improve diagnosis in health care by addressing systemic weaknesses, knowledge gaps, and training issues in the workforce.

Network of Patient Safety Databases Chartbook, 2020.

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Rockville, MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Pub. No. 20-0048.

AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2020, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between July 2012 and December 2019. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. This iteration of the chartbook contains an additional 619,111 reports not included in the prior NSPD chartbook.

Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis.

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Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.

Telehealth is becoming a standard care mechanism due to COVID-19 concerns. This special issue brief discusses telediagnosis, shares system and associate factors affecting its reliability, challenges in adopting this mode of practice, and areas of research needed to fully understand its impact. This issue brief is part of a series on diagnostic safety.

Digital Healthcare Research.

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Agency for Healthcare Research and Quality.

An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and health system improvement is still emerging. This website highlights Agency for Healthcare Quality and Research funded research and implementation projects supporting evidence creation and knowledge distribution on health care digital strategies.

Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary.

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Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.

Project RED re-engineered discharge with the goal of reducing preventable readmissions. This report summarizes an Agency for Healthcare Research and Quality project to transfer the Project RED experience to the primary care environment. Areas of focus included enhancing the team leader role of primary care physicians in post-discharge care.

Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2020 User Database Report.

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Famolaro T, Hare R, Thornton S, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2020. AHRQ Publication No. 20-0016.

The latest publication from the Agency for Healthcare Research and Quality (AHRQ) reports results of 282 ambulatory surgery centers (ASC) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. The majority of respondents (86%) rated their organization’s overall safety rating as excellent or very good.

SOPS Medical Office Database.

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Agency for Healthcare Research and Quality (AHRQ). March 2020.

This website provides a report and data repository representing medical offices that administered the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey. Insights on safety culture reflect practices from 1,475 medical offices and more than 18,000 respondents. The current data submission deadline is September 22, 2023.

Health Services Research Priorities for Improving Diagnostic Safety and Quality. Special Emphasis Notice (SEN).

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Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT-HS-20-004.

This announcement highlights AHRQ continued interest in research regarding the development of an evidence base on the incidence of diagnostic error, its presence in a variety of health care environment and its impact on patient outcomes.

Improving Quality of Care and Patient Outcomes During Care Transitions (R01).

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Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.

Communication during patient transitions carries the potential for mistakes that can result in patient harm. This program (funding) announcement will support the testing of interventions to improve communication and coordination during care transitions within and between a variety of care environments. Applicants are encouraged to incorporate a care transitions model such as Project RED into their research design. Applications are no longer being excepted.

Reducing Diagnostic Error: Measurement Considerations.

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National Quality Forum

This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.

AHRQ Health Services Research Project: Partners Enabling Diagnostic Excellence (R01).

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Agency for Healthcare Research and Quality; AHRQ; US Department of Health and Human Services; HHS.

Diagnostic error research is emerging as an area of focus in health care. This funding opportunity will support large research projects that seek to examine diagnostic processes and diagnostic errors in a variety of settings and patient populations. The application process is now closed.

Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions.

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Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.

Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.

Diagnostic Excellence Initiative.

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Gordon and Betty Moore Foundation.

Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite an increasing focus on diagnostic error, accurate measurement and implementation of effective strategies for mitigating its adverse effects remain challenging. The Gordon and Betty Moore Foundation recently announced a new $85 million initiative focused on diagnostic excellence that takes into account health care costs, timeliness, and individual patient needs. This initiative will focus on three clinical areas including cancer, infections, and cardiovascular events. Through this funding, the foundation hopes to stimulate novel approaches to measuring diagnostic performance and plans to assess the effectiveness of new technologies in improving the diagnostic process. A PSNet perspective highlighted ongoing challenges related to diagnostic error.

Wiser Healthcare.

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Australian National Health and Medical Research Council.

Overdiagnosis and the subsequent overuse of medical care contributes to unnecessary financial, psychological, and physical risk to patients. This research collaborative draws from expertise and experience from organizations in Australia investigating the problem of overdiagnosis and testing solutions to prevent medical care overuse.

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