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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 77 Results
Curated Libraries
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.

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.

Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.

Telehealth is becoming a standard care mechanism due to COVID-19 concerns. This special issue brief discusses telediagnosis, shares system and associate factors affecting its reliability, challenges in adopting this mode of practice, and areas of research needed to fully understand its impact. This issue brief is part of a series on diagnostic safety.
Kumar PR, Nash DB. Am J Med Qual. 2020;36:185-196.
The outpatient setting is receiving increased attention as a research focus in patient safety. This bibliography provides an annotated list of articles summarizing safety improvement efforts in the ambulatory setting since 2016. Topics explored include safety culture, measurement, team training, test result management, incident reporting, and diagnostic error.

HHS OIG Data Brief. Washington DC; Office of the Inspector General: May 4, 2020. Report number OEI-02-19-00130.

Misuse of prescription opiates in the US continues to be a patient safety concern.  This data brief summarizes characteristics of the Medicare Part D population that routinely use opiates. It provides insights into the prevalence of patients diagnosed with opioid use disorders and others at risk for abuse that receive prescriptions for opioids.  A recommendation shared to address the situation is to assure patients diagnosed with the disorder get the medication-assisted treatment they need.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
Boston, MA: Institute for Healthcare Improvement; 2018.
The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence assessment to provide recommendations to improve the safety of home-based care. The document outlines five guiding principles to enhance safety of home care, which include a focus on person-centered care, safety culture, learning and improvement systems, team-based and coordinated care provision, and incentive models.
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF.
A vibrant culture of safety is critical to achieving high reliability in health care. Organizations with stronger safety culture boast lower in-hospital mortality and fewer surgical site infections. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2018 comparative database report assessed 10 safety culture domains in nearly 2500 ambulatory care practices. Respondents reported high rates of teamwork and strong systems for patient follow-up. Many practices identified productivity pressures and work pace as safety hazards. Although the practices surveyed are not nationally representative, they do allow leaders and scientists to compare safety culture across practices and time. A past WebM&M commentary examined safety hazards associated with productivity pressures in health care.
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.
Philadelphia, PA: American College of Physicians; 2017.
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. This position paper highlights seven recommendations to address patient safety challenges in the ambulatory environment, including enhancing patient health literacy, utilizing team-based care models, and establishing a national effort to reduce patient harm across all settings of health care.
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
Incorporating patient safety in education and learning environments can augment physician engagement in quality and safety work. This publication outlines how organizations can enable new clinicians to develop a long-term patient safety focus through leadership involvement in safety culture and an infrastructure that supports reporting, transparency, and measuring improvements.
Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017.
Patient perspectives have been shown to identify otherwise undetected adverse events. This Institute for Healthcare Improvement–National Patient Safety Foundation commissioned survey, an update to their original 1997 survey, interviewed a probability-based sample of 2536 American adults. The results demonstrate the widespread nature of patient safety problems. Overall, 20% of respondents reported personally experiencing a medical error, most often in the outpatient setting. However, only 10% of respondents said they experienced harm when receiving medical care, which underscores the contrast between error and harm. The most common type of error was a missed or delayed diagnosis, followed by a communication error. About a third of errors were not reported. These results highlight the need to focus on diagnostic safety in the outpatient setting in order to improve patient safety in United States health care.