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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 38 Results
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Fischer H, Hahn EE, Li BH, et al. Jt Comm J Qual Patient Saf. 2022;48:222-232.
While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.
Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;36:3015-3022.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 
Sharma AE, Yang J, Del Rosario JB, et al. Jt Comm J Qual Patient Saf. 2021;47:5-14.
Ambulatory care settings are receiving increased attention as a focus for patient safety improvements. Using data from a multistate patient safety organization (PSO) database, the researchers sought to characterize patterns and characteristics of patient safety incidents reported in ambulatory care settings. Analyses found that 5.9% of events resulted in severe harm and 1.9% resulted in patient death. Over half of the events were from outpatient subspecialty care; fewer events occurred in home/community (5.2%), primary care (2.1%), or dialysis (2.0%) settings. Medication-related events were most common, followed by clinical deterioration and falls. Predictors of higher harm included diagnostic errors, patient/caregiver challenges, and events occurring in home/community or psychiatric settings. These results can help ambulatory care settings target safety events and develop systems-level prevention strategies.  
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  

Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.   

Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses).  The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.  
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.

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.
Sunshine JE, Meo N, Kassebaum NJ, et al. JAMA Netw Open. 2019;2:e187041.
The seminal report, To Err Is Human, famously estimated that 44,000 to 98,000 deaths per year in the United States were due to medical errors. Although certain patient harms thought to be unavoidable at the time of the report's publication in 1999 are now considered completely preventable, experts suggest that progress in the field of patient safety has been slower than initially anticipated and that areas such as ambulatory safety and diagnostic error represent emerging priorities. In this cohort study, researchers used data from 1990 through 2016 on mortality related to the adverse effects of medical treatment (AEMT) from the Global Burden of Diseases, Injuries, and Risk Factors 2016 study. For the study period, researchers attribute 123,603 deaths to AEMT. The number of such deaths increased, but the US age-standardized mortality rate for deaths due to AEMT decreased by 21% between 1990 and 2016. The authors noted similar AEMT mortality rates for men as compared to women, significantly increased AEMT mortality rates for those age 70 and older, and geographic variation with regard to age-standardized AEMT mortality rates. An Annual Perspective discussed challenges associated with measuring and responding to deaths associated with medical errors.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.