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 992 Results

When we're all responsible for a patient's death, no one is.

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Prasad V, Medpage Today. November 16, 2021.

The issue of system versus individual accountability can challenge the orientation of safety improvement efforts. This opinion piece discusses the importance of physician recognition of decision making mistakes and the downside of the evolution of morbidity and mortality conferences away from that approach.

How low can they go? Rural hospitals weigh keeping obstetric units when births decline.

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Huff C. Kaiser Health News. November 12, 2021.

This article discusses the challenge of providing safe maternity care in rural environments when demand for service cannot support its cost, and keeping teams actively experienced in provision of reliable maternal care.

Debriefing for Clinical Learning

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Patient Safety Primer November 18, 2021

Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.

Challenges with requiring five characters during ADC drug searches via override.

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ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.

Shortcuts in automated data entry behaviors have potential to result in errors. This article discusses search term length requirements for automated dispensing cabinets and the importance of doing a proactive failure analysis prior to implementing any system conditions to minimize unintended consequences of the rules that could detract from safety.

Anatomy of a medical device recall: How defective products can slip through an outdated system.

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Zipp R. Medical Tech Dive. October 18, 2021.

This article highlights systems influences that detract from the effectiveness of current methods of reporting recalled unsafe medical devices and raising awareness of recalls for clinicians, patients and families. Challenges highlighted include the use of paper-based notification systems and data reporting delays.

Deprescribing as a Patient Safety Strategy

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Patient Safety Primer October 27, 2021

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

The Role of Community Pharmacists in Patient Safety

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Perspective on Safety October 24, 2021

This piece discusses the critical role community pharmacists play in ensuring medication safety.

In Conversation With... Georgia Galanou Luchen, Pharm. D.

Georgia Galanou Luchen, Pharm. D., is the Director of Member Relations at the American Society of Health-System Pharmacists (ASHP). In this role, she leads initiatives related to community pharmacy practitioners and their impact throughout the care continuum. We spoke with her about different types of community pharmacists and the role they play in ensuring patient safety.

Disrespectful behavior in healthcare: has it improved? Please take our survey!

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ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares errors reported to the ISMP Vaccine Errors Reporting Program and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Health Equity and Maternal Health

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Perspective on Safety October 6, 2021

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.

Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?

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Clark C. MedPage Today. September 14, 2021.

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

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.

Geriatric medication reconciliation in the home setting.

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Taylor K. American Nurse J. 2021;16(7):14-17.

Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.

Machine learning is booming in medicine. It’s also facing a credibility crisis.

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Ross C. STAT. June 2, 2021.

Artificial intelligence and machine learning are often promoted as tools with impressive potential for generating rapid improvements in healthcare decision making. This news story highlights how underlying problems and testing failures limit the trustworthiness of conclusions drawn by the systems.

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

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ISMP Medication Safety Alert! Acute Care Edition. May 6, 2021;26(9):1-4.

Look-alike labeling is a known contributor to medication errors. This article summarizes common factors resulting in packaging and labeling concerns. Recommendations for improvement include partnerships with industry regarding the use of risk management practices to improve the accuracy of labeling prior to product launch.

Addiction treatment providers in Pa. face little state scrutiny despite harm to clients.

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Pattani A, Mahon E. Kaiser Health News. April 30, 2021.

Systemic oversight weaknesses and lack of accountability undermine treatment effectiveness and safety. This article describes failures in addiction treatment that contributed to harm for vulnerable patients seeking help.

Black or 'other'? Doctors may be relying on race to make decisions about your health.

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Smith J, Spodak C. CNN. April 25, 2021.

Race-adjusted decision making tools perpetuate the potential for diagnostic error and care delay. This article examines race correction as a form of bias in health care and discusses efforts to reduce the use of race-adjusted algorithms.

Survey by Ohio regulator shows stress, fatigue among pharmacists at chain stores.

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Kaplan A. NBC News. April 21, 2021.

Pharmacies are high-pressure environments generating conditions that undermine safety. This story highlights working conditions in chain pharmacies that cause concerns for pharmacists in their ability to prepare and dispense medications safely due to lack of appropriate staffing and time to do their jobs.

Nursing and Patient Safety

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Patient Safety Primer April 21, 2021

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.

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