Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Search By Author(s)
Displaying 1 - 8 of 8 Results

Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.
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.

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.
Sjoding MW, Dickson RP, Iwashyna TJ, et al. N Engl J Med. 2020;383:2477-2478.
Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.

People’s Pharmacy.  Show 1209. April 28, 2020.

Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in medicine. She draws from both general and COVID-19 pandemic care experiences to illustrate the difficulties involved in measuring, understanding and improving patient safety.
Human factors expertise in targeted personnel is a noted health care system improvement strategy. This news piece highlights the National Health Service (NHS) effort to require organizations to develop and employ patient safety specialists with distinct human factors and safety science skill sets to embed system improvements in their organizations and throughout the NHS.
MedStar Health National Center for Human Factors in Healthcare.
Electronic health records (EHR) optimize information functions in care environments while paradoxically introducing inefficiencies and opportunities for error due to usability problems. This series of videos draws from usability research to illustrate how ineffective EHR design can reduce the safety and reliability of care processes that rely on these systems.
Ornstein C. Los Angeles Times. September 16, 2014.
This article discusses one couple's decision to hold a pharmaceutical company legally accountable for package and label designs they believe contributed to the heparin overdose of their twin infants.