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 48 Results

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.

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.

I can't turn my brain off.

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Hoffman J. New York Times. May 16, 2020.

Health care worker stress is a known contributor to disruptive behavior, error and clinician suicide. This story discusses the impact of the COVID-19 pandemic on psychological strain in clinicians and highlights peer support and other techniques to mitigate its negative effects.

Falls

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Patient Safety Primer September 7, 2019

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

My human doctor.

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Peskin SM. New York Times. October 4, 2018.

Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.

Avoidable sepsis infections send thousands of seniors to gruesome deaths.

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Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.

Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.

Preventing newborn falls and drops.

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Quick Safety. March 27, 2018;(40):1-2.

Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.

Medicare failed to investigate suspicious infection cases from 96 hospitals.

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Jewett C. Kaiser Health News. May 9, 2017.

The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.

Zero tolerance for deadly hospital-acquired infections.

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Levine H. Consum Rep. 2017;82:32-40.

Hospital rating systems have yet to receive approval across the health care industry, but they still serve as a way for consumers to select hospitals and providers. This news article reports on publicly available data for central line infections in hospitals across the United States and spotlights checklists as a strategy that contributes to improvement. The article also ranks teaching hospitals based on their performance at preventing central line infections.

'Superbug' scourge spreads as U.S. fails to track rising human toll.

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McNeill R; Nelson DJ; Abutaleb Y.

Antimicrobial resistance is a pervasive threat to patient safety. This news article discusses incidents involving methicillin-resistant Staphylococcus aureus (MRSA) infection to spotlight the need for health care to develop system-level approaches to measuring the problem and enforce regulations designed to prevent health care–associated infections. A PSNet perspective described one nurse's experience with MRSA as a patient.

Making health care safer. Think sepsis. Time matters.

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CDC; Centers for Disease Control and Prevention.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Making health care safer: protect patients from antibiotic resistance.

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CDC; Centers for Disease Control and Prevention.

Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.

Doctors debate safety of their white coats.

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Butler DL, Major Y, Bearman G, et al. The Journal of hospital infection. 2010;75:137-8.

Studies have sought to determine if clinician attire contributes to the transmission of hospital-acquired infections. This newspaper article reports insights from physicians regarding whether white coats can spread germs in the hospital environment.

The overlooked danger of delirium in hospitals.

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Hshieh TT, Yue J, Oh E, et al. JAMA internal medicine. 2015;175:512-20.

Delirium is a common unintended consequence of hospitalization, most often following a surgical procedure. This magazine article discusses characteristics of the condition, contributing factors, challenges to diagnosing it, and strategies to reduce its incidence. A previous AHRQ WebM&M commentary describes the key diagnostic differences between delirium and dementia.

Malnourishment 'epidemic' plagues hospitals? Really?

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Clark C. HealthLeaders Media. September 18, 2014.

This news article explores the validity of recent reports by an interdisciplinary consortium that one in three hospitalized patients is malnourished and suggests further research is required to understand this potential patient safety problem.

Physician: 'I almost killed a patient' because of an advance directive.

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Betbeze P. HealthLeaders Media. May 2, 2014.

Reporting on how misinterpretation of advance directives and living wills can detract from patient safety, this news article reveals insights from a physician who developed a checklist poster to provide decision support for clinicians and recommends standardization of the forms to reduce risks.

How Does Infection Prevention Fit Into a Safety Program?

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Perspective on Safety March 1, 2014

This piece describes the history around efforts to address preventable health care–associated infections, including federal initiatives and further research avenues to consider.

In Conversation With… Alison Holmes, MD, MPH

Dr. Holmes is Director of Infection Prevention and Control and a professor at Imperial College London. We spoke with her about infection prevention and patient safety.

A guide for HCAs on safe patient transfers.

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Lees L.

This commentary offers practical advice for health care assistants to reduce risks during patient transfers.

Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit

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Perspective on Safety December 1, 2012

This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.

In Conversation With… Sharon K. Inouye, MD, MPH

A leading expert in geriatrics research and innovation, Dr. Inouye developed and validated a widely used tool, the Confusion Assessment Method (CAM), to identify delirium.

Sterile compounding tragedy is a symptom of a broken system on many levels.

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ISMP Medication Safety Alert! Acute Care Edition. October 18, 2012;17:1-4.

This piece reviews risks associated with the use of compounding pharmacies and recommends that legislative oversight can improve medication safety.

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