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 - 10 of 10 Results

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.

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.

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.

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.

Industrial and Systems Engineering and Health Care: Critical Areas of Research: Final Report.

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Valdez RS, Ramly E, Brennan PF. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 10-0079-EF.

This workshop report explores why efforts to apply industrial and systems engineering (ISyE) knowledge to health care have been generally unsuccessful and suggests a research and action agenda using ISyE knowledge to create an ideal health care delivery system.

Advances in Patient Safety: New Directions and Alternative Approaches.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).

The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.

Advances in Patient Safety: From Research to Implementation.

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Henriksen K, Battles JB, Marks ES, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality (US); 2005.

With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine’s report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.

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