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 22 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.

Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.

ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative.

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Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learning Environments: Pathway Leaders Patient Safety Collaborative. Chicago, IL: Accreditation Council for Graduate Medical Education. September 30, 2020. ISBN: 978-1-945365-36-2.

The clinical learning environment (CLE) situates the development of safety behaviors in resident and fellow physicians, students, and staff. This report highlights results of an 18-month collaborative to design tactics that engage resident and fellows in patient safety work through event analysis. Lessons learned supporting success include assessment of the learner experience and dedication of time to enable participation.

How administrative burdens can harm health.

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Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.

The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. This policy brief examines how administrative burdens can separate patients from the care they need and calls for increased attention to the problem.

Global Report on the Epidemiology and Burden of Sepsis: Current Evidence, Identifying Gaps and Future Directions.

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Geneva, Switzerland; World Health Organization: September 2020. ISBN 9789240010789.

Sepsis diagnosis, prevention and treatment are global challenges. This report discusses sepsis management with a focus toward understanding its impact on distinct populations to inform research and policy improvement approaches.

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.

What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.

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Sheridan S, Merryweather P, Rusz D, et al. Washington, DC: National Academy of Medicine; 2020.

Safety initiatives can be enhanced by engaging patients in the development process. This report highlights one project as an example of how to involve patients as partners in diagnostic improvement research projects. The program resulted in a curriculum that prepared patients to participate as team members in diagnostic improvement studies.

Improving care by using patient feedback.

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National Institute for Health Research. Southampton, UK: NIHR Dissemination Centre; December 2019.

Patient feedback is a problematic source of patient safety improvement information. This report shares results from nine patient feedback studies in the United Kingdom. Gaps found in the mechanisms reviewed include lack of effective application of data collected and sharing the feedback with frontline staff to improve their practice.

Still Not Safe: Patient Safety and the Middle-Managing of American Medicine.

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Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268.

The modern patient safety movement has struggled to achieve the goals set forth in To Err Is Human. This book surveys the evolution of the collective error reduction effort in health care. The authors analyze the experience through social, legal, market, psychological and medical practice trends. They submit that the clinician-driven focus of improvement is reducing the momentum needed for lasting change. The publication provides recommendations to generate the improvement needed do minimize patient harm, notably the involvement of safety scientists.

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

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London, UK: Royal College of Surgeons of England; 2019.

Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.

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.

Improving Usability, Safety and Patient Outcomes With Health Information Technology.

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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.

Organizing for Reliability: A Guide for Research and Practice.

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Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612.

High reliability principles guide safety efforts in complex organizations. This guide provides an overview of key concepts associated with reliability and highlights areas of growth needed to ensure health care organizations can develop and sustain high reliability practices.

A Crisis in Health Care: A Call to Action on Physician Burnout.

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Jha AK, Iliff AR, Chaoui AA, et al. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019.

Clinician well-being affects the safety of the care environment. This publication suggests that the ramifications of physician burnout are a public health concern. The report provides an overview of the burnout crisis and recommends strategies to address the problem, including mental health initiatives, electronic health record enhancements, and appointment of chief wellness officers.

Research in Ambulatory Patient Safety 2000-2010: A 10-Year Review.

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Lorincz CY, Drazen E, Sokol PE, et al. Chicago, IL: American Medical Association; 2011.

Although traditionally the majority of patient safety efforts have focused on inpatient care, the overwhelming bulk of health care actually takes place in the ambulatory setting. Accordingly, the scope of widespread documented adverse events among outpatients is vast. Updating a previous report, this publication analyzes efforts to improve patient safety in ambulatory care over the past decade and identifies gaps that future research should address. Dr. Richard Baron discusses patient safety in the office setting in an AHRQ WebM&M perspective.

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.

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