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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 876 Results

Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN: 9781945365416.

Health care provision requires continuous learning to enhance skills, collaboration, and system awareness. This report discusses characteristics of an environment that nurtures learning across disciplines in health care. It centers on 6 areas of focus: patient safety, quality, teaming, supervision, well-being, and professionalism.

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.
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.
Perspective on Safety October 24, 2021

This piece discusses the critical role community pharmacists play in ensuring medication safety.

This piece discusses the critical role community pharmacists play in ensuring medication safety.

Gina Luchen

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. 

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.

Graber ML, Schrandt S. Evanston, IL:  Society to Improve Diagnosis in Medicine;  September 8, 2021. 

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.

Ridge K. London, England: Crown Copyright; 2021. September 22, 2021.

Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has long reduced medication safety across the spectrum of health care. The report examines the systemic and cultural issues that contribute to overprescribing and recommends a governmental leadership position to drive change and implement deprescribing and other reduction initiatives.
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.

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.

Alison Stuebe photo

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.

Atlanta, GA: Centers for Disease Control and Prevention; October 2021.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2020 revealed increases in central line–associated bloodstream infections and other infections while a decrease in surgical site infections. The current report also discusses the impact of COVID-19 on reporting and data submission efforts.
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.

Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19. 

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Geneva, Switzerland: World Health Organization; 2021. ISBN: 9789240032705.

The World Health Organization has released the Global Action Safety Plan 2021-2030. This plan provides strategic policy and implementation direction for a wide range of clinical and governmental organizations who work with patient safety. The plan has seven strategic objectives – (1) policies to eliminate avoidable harm, (2) high-reliability systems, (3) safety of clinical processes, (4) patient and family engagement, (5) health worker education, skills, and safety, (6) information, research, and risk management, and (7) synergy, partnership, and solidarity
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.

Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021.  ISBN: 9789240029200

Advanced computing technologies can help or hinder safe care. This guidance summarizes ethical concerns and risks stemming from the influx of artificial intelligence (AI) into decision making throughout health care. The report provides 6 tenets to guide AI implementation worldwide and shares governance recommendations to ensure the clinical and public health impacts of AI are equitable, responsible and safe.

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.  

Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021.

Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a challenge. This strategic curricula supports the implementation of a national United Kingdom initiative through the engagement of educational programs to train health professionals in the foundations of safe care. 

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.

Farnborough, UK: Healthcare Safety Investigation Branch; April 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.