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Patient Safety Network

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 325 Results
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    • Changing experience of adverse medical events in the National Health Service: comparison of two population surveys in 2001 and 2013.
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    • Gray AM, Fenn P, Rickman N, et al. Soc Sci Med. 2017;195.
    … Science & Medicine … Soc Sci Med … This study compared two population-based surveys in the United Kingdom regarding … public perceptions of adverse events associated with health care, one from 2001 and the other in 2013. Researchers … that medical care has become safer in the National Health Service. …
    Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study.
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    • Usher M, Sahni N, Herrigel D, et al. J Gen Intern Med. 2018;33:1447-1453.
    … during hospitalization. Hospital transfers where a health information exchange (HIE) was in place had fewer … M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study.  J Gen Intern Med . 2018;33(9):1447-1453. …
    Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.
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    • Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17:e821-e828.
    … J Patient Saf … Using data from the Veterans Health Administration National Center for Patient Safety , … adverse events occurring among the homeless veteran population in the Veterans Health Administration. J Patient Saf. Epub 2021 Aug 19. …
    Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.
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    • Bell SK, Dong J, Ngo L, et al. BMJ Qual Saf. 2022;Epub Feb 4.
    Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.
    Patient Safety Concerns and the LGBTQ+ Population
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    • Perspective on Safety February 1, 2023

    This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.

    This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.

    Connor Wesley
    In Conversation with Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population

    Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.

    How Can Health Care Organizations Become More Health Literate?: Workshop Summary.
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    • Hernandez LM; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: The National Academies Press; 2012. ISBN: 9780309256810.
    … This report details the results of a workshop on health literacy in health care organizations. … Hernandez LM; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of … of Medicine; IOM; Roundtable on Health Literacy; Board on Population Health and Public Health Practice … LM … Hernandez …
    Implications of Health Literacy for Public Health: Workshop Summary.
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    • Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
    … Health literacy can affect patients' ability to understand … M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of … 9780309303651. … Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of …
    Health Literacy: Past, Present, and Future: Workshop Summary.
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    • Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN: 9780309371544.
    Efforts to develop patients' ability to understand health information and follow treatment recommendations can enhance medication safety and engage patients in their care. The Institute of Medicine highlighted health literacy as a safety concern in 2004. This report summarizes the findings of a workshop convened to assess progress in this field and to discuss local, national, and international strategies to advance health literacy improvement.
    Master of Science in Healthcare Quality and Safety.
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    • Philadelphia, PA: Thomas Jefferson University School of Population Health.
    … … Philadelphia, PA: Thomas Jefferson University School of Population Health. … Thomas Jefferson University; TJU; Thomas Jefferson University School of Population Health; JSPH …
    Facilitating Patient Understanding of Discharge Instructions: Workshop Summary.
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    • Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383.
    … Poor health literacy has been identified as an important threat to … J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of … 9780309307383. … Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of …
    Maternal Safety and Perinatal Mental Health
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    • Perspective on Safety March 29, 2023
    … during the in-hospital stay, perinatal care crosses the health continuum. It is essential to address patient safety … 9, which have been validated for use with the perinatal population. 3 Screening alone is not effective in addressing … MC, et al. Maternal morbidity rates in a managed care population. Obstet Gynecol . 2008;111(5):1089-1095. …

    This piece focuses on perinatal mental health and efforts to improve maternal safety.   

    Christie Allen
    In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health

    Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery

    Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study.
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    • Concha OP, Gallego B, Hillman K, et al. BMJ Qual Saf. 2014;23:215-22.
    … mechanism for this finding is unknown and could be due to health care system factors (i.e., lower weekend staffing and … and at higher risk of death than weekday admissions). This population-based analysis from New South Wales, Australia sought to determine the contribution of health care system and patient factors to elevated weekend …
    Standardizing Medication Labels: Confusing Patients Less, Workshop Summary.
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    • Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2008.
    … to help prevent errors. … Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of … Press; 2008. … Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of …
    Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study.
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    • Sundwall DN, Munger MA, Tak CR, et al. Health Equity. 2020;4:430-437.
    This study surveyed 9,206 adults across the United States about their perceptions of medical errors occurring in ambulatory care settings. Thirty-six percent of respondents perceived that their doctor has ever made a mistake, provided an incorrect diagnosis, or given an incorrect (or delayed) treatment. According to these findings, patient-perceived medical errors and harms occurred most commonly in women and those in poor health with comorbid conditions.  
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