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 294 Results

Medicine's Shadowside: Revisiting Clinical Iatrogenesis.

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Varley E, Varma S, eds. Anthropol Med. 2021;28(2);141-278.

Implicit biases are rooted in culture and context. This special issue examines a broad range of influences and impacts of medical harm enabled by societal acceptance of inequalities both within medicine and beyond it.

Empowering Patients and Supporting Health Care Providers—New Avenues for High Quality Care and Safety.

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Rimondini M, Busch IM, eds. Int J Environ Res Public Health. 2021;18.

Patient/clinician relationships supported by organizational culture and individual wellness efforts are core to the provision of high-quality care and process improvement engagement. This article collection highlights trainee attitudes about patient safety and how respect and support for enhancing the care experience of both patients and those who care for them are foundational to safe, effective care.

The 2020 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2021;47(8):463-488.

The Eisenberg Award honors individuals and organizations who have made significant advancements in the pursuit of safe, high-quality health care. The 2020 honorees are Dr. David Gaba; Veterans Health Administration Rapid Naloxone Initiative, Washington, DC, and Northwestern Medicine Academy for Quality and Safety Improvement, Chicago IL.

Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.

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Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.

Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff. This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.

Safety and Quality in Perioperative Anaesthesia Care.

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Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.

Surgical patients are at high risk for harm, should errors occur. This special issue covers areas of concern in perioperative anesthesia care that include patient allergies, age, sex and gender considerations, and incident reporting system effectiveness.

Medical Residents and Burnout

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Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21.

Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This issue covers a range of topics exploring the mental health consequences of residency, factors influencing well-being, and approaches to help individuals successfully navigate the stress of residency.

Safety and Quality in Perioperative Anesthesia Care.

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Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.

The field of anesthesiology has realized impressive improvements in safety, yet challenges still exist in its practice. This special issue provides discussions on a variety of concerns that require continued effort, including use of early warning scores, differences associated with sex and gender, and use of incident reporting systems.

Human Factors and Ergonomics in Healthcare.

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Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.

Human factors approaches have been identified as one of the primary vehicles to create lasting patient safety innovation. Articles in this special supplement examine the role of human factors engineering and ergonomics in establishing improvement in organizational learning, pandemic response, and primary care management.

COVID-19 Content. ISMP Medication Safety Alert!

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March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.

Two decades since To Err Is Human: progress, but still a "chasm".

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Dzau VJ, Shine KI. JAMA. 2020;324:2489-2490.

To Err is Human and Crossing the Quality Chasm changed the trajectory of improvement efforts worldwide. This editorial and the associated viewpoints outline the impact of the reports on global, COVID-19, anesthesiology, and ambulatory care.

Patient Safety

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Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.

Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism.

Missed or Rationed Nursing Care.

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J Nurs Manag. 2020;28(8): i-iv, 1767-2275.

Incomplete nursing care is known to affect care quality and safety. This special issue documents the global problem of missed or rationed nursing care in a variety of settings and countries. Articles featured in this special issue examine systemic issues, explore interventions, and evaluate measurement tools.

Technology, Education and Safety.

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Ruskin KJ, ed. Curr Opin Anaesthesiol. 2020;33(6):774-822.

The complexity of care delivery requires complementary approaches to prevent mistakes. This special section shares clinical and organizational tactics to address anesthesiology safety issues. They include automation failures, the role of the obstetric anesthesiologist in maternal safety, and monitoring effectiveness.

Digital Health and Patient Safety.

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Health Informatics J. 2020;26:181-189;576-591;683-718;1017-1042;2295-2299;3123-3162.

This special collection examines the use of novel health information technology (HIT) to promote patient safety and challenges in examining the impact of those technologies. Articles featured in this issue include a focus on qualitative approaches to evaluating the impact of HIT on patient safety, particularly through a sociotechnical lens.

COVID-19: The Diagnostic Challenge.

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Diagnosis (Berl). 2020;7(4):345-411.

COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.

Management of Operating Room Critical Events.

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Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922.

Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on management of, and preparation for, perioperative critical events and rescue should they occur. The authors highlight simulation training, debriefing, and cognitive aids as methods for improving safety in the operating room.

High-Performance Work Systems in Health Care Management: Parts 1-5.

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Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.

Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer III Report.

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J Patient Saf. 2020;16:s1-s56.

The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.

Becoming a High Reliability Organization.

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VHA Forum. Summer 2020;1-12.

High reliability attainment is a stated goal for health care organizations. This special issue covers established initiatives at the United States Veterans Health Administration that draw from high reliability principles to improve care. Topics covered include evaluation priorities, safe patient handling and diagnostic safety.

Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error.

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Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

Challenges to effective clinical reasoning reduce diagnostic accuracy. This special issue provides background for a new approach to clinical reasoning: situativity. The articles explore the four complementary facets of the concept -- situated cognition; distributed cognition; embodied cognition; and ecological psychology – and describes how situativity can enhance diagnosis through a holistic approach to education, assessment, and research.

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