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 549 Results

Hospital Performance Report.

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Trenton, NJ: New Jersey Department of Health and Senior Services.

Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.

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.

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.

Mirror, Mirror 2021: Reflecting Poorly

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Schneider EC, Shah S, Doty M, et al. New York, NY: The Commonwealth Fund; August 2021.

A cross-national survey of consumers and physicians reveals that, despite its costliness, the United States health care system continues to rank lower than other countries in quality of care performance.

National Diabetes Inpatient Audit -- Harms.

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Leeds, UK: Health and Social Care Information Centre.

This annual report identified a significant number of medication errors associated with diabetes care in acute hospitals in England and Wales.

Decision Making in Emergency Medicine: Biases, Errors and Solutions.

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Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422.

Decision making is vulnerable to human influences such as fatigue, interruption and bias. This book provides case examples of how 60 cognitive biases can degrade clinical reasoning in the emergency department and shares tactics that minimize their potential impact on thinking.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

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National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; 2021. ISBN: 9780309685061.

Health care system safety and effectiveness requires an engaged and empowered nursing workforce. This report builds on the foundation of nursing as a core care contributor. It shares a framework positioning nurses to improve equity, reduce disparities and support family-centered care in the future through education, healthy work environments and enhanced professional autonomy.

Medical Office Survey: 2020 User Database Report.

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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.

Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics?

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Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.

Each Baby Counts.

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Royal College of Obstetricians and Gynaecologists.

This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making.

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Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.

Diagnostic error reduction methods are evolving to enhance efforts supporting diagnostic improvements. This publication uses clinical cases to examine cognitive elements that contribute to problematic decision making. The model illustrates how bias and other reasoning flaws are more likely to result in diagnostic errors than a lack of knowledge would.

Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis.

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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.

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

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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.

Making Healthcare Safer III.

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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.

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey.

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Washington DC: Leapfrog Group; 2020.

Surgical volume standards are a metric used to assess the needed experience in performing distinct types of procedures. This report analyzed data from over 2,100 hospitals and found approximately half to be deficient in fully adhering to the standards while implementing mechanisms to minimize unnecessary surgeries

National Patient Safety Syllabus 1.0 Training for all NHS Staff.

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London, UK: Academy of Medical Royal Colleges; 2020.

A foundational understanding of safety is core to building reliable care processes and teams. This report outlines a curriculum that was developed in response to a national improvement strategy for National Health Service staff. The training program highlights the themes of the systems approach, risk competencies, human factors and safety culture as linking content domains together to develop safe practitioners.

Checking In on the Checklist.

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Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.

Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.

Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety & Risk Reduction.

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Plymouth Meeting, PA: ECRI Institute; 2019.

Outpatient safety is gaining traction as a focal point of analysis and improvement efforts. This patient safety organization analyzed 4,355 incident reports from outpatient providers to identify five areas of concern: diagnosis, medications, falls, privacy, and physical safety.

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2019. ISBN: 9780309495509.

Clinician burnout is a known contributor to unsafe care. This report summarizes evidence on the causes and impacts of clinician burnout. The authors share six recommendations for improvement which include redesign of the learning environment, technologies, and support services for clinicians.

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