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 472 Results

An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust.

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Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.

Hospital Performance Report.

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Trenton, NJ: New Jersey Department of Health and Senior Services.

Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.

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.

A Thematic Analysis of HSIB's First 22 Investigations.

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Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.

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.

The Safety of Maternity Services in England.

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Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital?

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Gangopadhyaya A. Washington DC; Urban Institute: July 2021.

Racial inequities have been revealed by the COVID pandemic as a distinct patient safety concern. This report examined racial differences using patient safety indicators to measure hospital-acquired conditions, insurance coverage, and hospital patient population. The results indicate Black patients have reduced safety, that insurance coverage had little influence on safety and hospitals with a higher Black patient population experienced more adverse events that those serving a white patient population.

National Diabetes Inpatient Audit -- Harms.

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Leeds, UK: Health and Social Care Information Centre.

This annual report identified a significant number of medication errors associated with diabetes care in acute hospitals in England and Wales.

Decision Making in Emergency Medicine: Biases, Errors and Solutions.

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Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422.

Decision making is vulnerable to human influences such as fatigue, interruption and bias. This book provides case examples of how 60 cognitive biases can degrade clinical reasoning in the emergency department and shares tactics that minimize their potential impact on thinking.

Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment.

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Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health. May 20, 2021.

Magnetic resonance imaging (MRI) suites harbor unique hazards that can harm patients, should process missteps occur. This report shares assessment steps to assure that medical devices are labeled appropriately to support their safe use in the MRI environment and encourages organizational reporting of problems encountered when testing device use.

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

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Washington DC: Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.

Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.

CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas.

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Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative and Procedural Subprotocol National Advisory Group, and the CLER Program. Chicago, IL: Accreditation Council for Graduate Medical Education; February 2021. ISBN: 9781945365386.

The teaching hospital environment can produce clinician behaviors and mindsets that persist throughout a medical career. This report from a clinical learning environment assessment program shares insights gathered during walking rounds specific to perioperative care and general medicine. The report concluded that residents did not actively report problems and rarely participated in event investigations.

Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics?

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Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.

Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions.

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Gangopadhyaya A. Washington DC: Urban Institute; March 29, 2021.

Racial inequities affect the safety of medical care. This report analyzed 2017 discharge records using patient safety measures from 26 states to identify differences in adverse events and hospital-acquired conditions in Black and White patients. The results suggest that hospital availability for admission may be a driver to safety for both Black and White patient populations and point toward policy solutions for disparity reduction.

Each Baby Counts.

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Royal College of Obstetricians and Gynaecologists.

This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

Surveys on Patient Safety Culture(TM) (SOPS®) Hospital Survey 2021 User Database Reports.

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Famolaro T, Hare R, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2021. AHRQ Publications Nos. 21-0016(1.0) and 21-0017(2.0).

Establishing culture of safety is an essential component to develop high reliability organizations and ensure patient safety. The AHRQ Hospital Survey on Patient Safety Culture is a validated survey that examines organizational perceptions about safety culture ranging from communication about errors to teamwork within and across units. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The 2021 SOPS Hospital 1.0 Database Report includes 320 hospitals and 191,977 respondents, and the 2.0 Database Report includes 172 hospitals and 87,856 respondents. In both reports, areas of strength included teamwork within units and leadership, and respondents reported concerns about handoffs and transitions. The 1.0 Database Report also noted concerns about leadership expectations and actions for promoting safety, and the 2.0 Database Report noted concerns about staffing and work pace.

Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.

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Mangus CW, Singh H, Mahajan P. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 20(21)-0040-4-EF.

Health information technology (Health IT) presents opportunities to engage patients and families in decision making. This issue brief highlights health IT tools that can close this communication gap to engage patients in diagnosis in the emergency room. This brief is part of a publication series examining diagnostic improvement across health care.

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed.

Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0

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La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.

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