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 1135 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.

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Anatomy of a medical device recall: How defective products can slip through an outdated system.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

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.

Parenteral nutrition safety.

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Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.

Can hospitals learn about safety from airlines?

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Pasztor A. Wall Street Journal. September 2, 2021.

Aviation continues to serve as an exemplar for healthcare safety efforts. This story highlights work toward the development of a National Patient Safety Board for medicine to establish a neutral centralized body to examine errors and share improvements driven by a robust self-reporting culture similar to that in commercial aviation.

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.

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

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ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.

Error reporting is an essential contributor to system safety improvement. This article examines weaknesses in error reporting behaviors, characteristics of organizations and technologies that facilitate underreporting and ineffective report analysis. The piece shares recommendations to enhance adverse event reporting to support learning.

Use systems redesign and the law to prevent medical errors and accidents.

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Saks MJ, Landsman S. STAT. August 4, 2021.

This article introduces the systemic task of medical error reduction and discusses the need for a business case, enterprise-wide accountability and legal process change to drive improvement.

'There is a real cost’: as Covid shows, barring bedside visitors from ICU deprives patients of the best care.

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Renault M. STAT. July 28, 2021.

Care and safety concerns for patients, families, and clinicians continue to be challenged by COVID-19. This article discusses the unintended consequences of isolation practices during the pandemic as a contributor to patient harm due to resultant family support barriers and loneliness they caused.

Diagnostic safety event reporting.

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Carr S. ImproveDx. July 2021;8(4).

Adverse event reporting can clarify when mistakes happen and what reduction strategies to apply. This article describes existing efforts to examine diagnostic error through reporting and highlights tactics being employed.

Federal speech rulings may embolden health care workers to call out safety issues.

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Meyer H. Kaiser Health News. July 9, 2021.

Whistleblower protections are a key component to raising awareness of safety issues in work environments. This news story examines how US federal law has opened the door for the media as a platform for employees to highlight conditions that reduce staff and patient safety in health care environments.

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.

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

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ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.

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