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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 21 Results
Sachs JD, Karim SSA, Aknin L, et al. Lancet. 2022;400:1224-1280.
COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19:s14-s26.
The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.  
Osborne V. Curr Opin Psychiatry. 2021;34:357-362.
The opioid epidemic is an ongoing patient safety issue. This literature review examined the impact of the COVID-19 pandemic on opioid surveillance research in the United Kingdom. Of studies conducted during the pandemic, most explored the impact of the pandemic on access to opioids or opioid substitution therapy.
Pifarré i Arolas H, Vidal-Alaball J, Gil J, et al. Int J Environ Res Public Health. 2021;18:5335.
The beginning of the COVID-19 pandemic immediately changed how patients sought healthcare. This study analyzed the change frequency of diagnoses made in 2019 compared to 2020 in one region of Spain. On average, the number of diagnoses declined 31% from 2019 to 2020, with cancer diagnoses declining by nearly 50%. As COVID-19 cases continue to decrease in many areas in 2021, the authors recommend local, regional, and national public health leaders prioritize plans to target under-diagnosed conditions.
Sloane PD, Yearby R, Konetzka RT, et al. J Am Med Dir Assoc. 2021;22:886-892.
Racial bias and racism are increasingly seen as a critical patient safety issue. In this article, the authors outline the components of systemic racism (structural/institutional, cultural, and interpersonal), how they manifest and affect the long-term care system, and the detrimental impact of systemic racism on Blacks during the COVID-19 pandemic.
Barranco R, Vallega Bernucci Du Tremoul L, Ventura F. Int J Environ Res Public Health. 2021;18:489.
Health systems have implemented various strategies to reduce the risk of nosocomial transmission of the COVID-19 virus. Based on ten studies, the authors estimate that the nosocomial transmission rate is 12-15%. The authors discuss the role of infection prevention and control procedures, and the potential implications of hospital-acquired COVID-19 on medical malpractice.  
Wessels R, McCorkle LM. J Healthc Risk Manag. 2021;40:30-37.
The COVID-19 pandemic has disrupted healthcare delivery. This study reviewed data from a large medical professional liability company to explore guidance sought by physicians and dentists during the initial months of the pandemic. Providers’ questions and concerns primarily involved operations (e.g., access to personal protective equipment, liability coverage), patient care (e.g., guidance for screening patients), scope of practice, and use of telemedicine.    
Richterman A, Meyerowitz EA, Cevik M. JAMA. 2020;324:2155.
Health systems have taken various approaches to reduce hospital transmission of COVID-19. These authors discuss the impact of universal masking policies for healthcare professionals and patients, dedicated break space, minimizing the use of shared patient rooms and regular testing with short turnaround times on hospital-acquired COVID-19.
Piatek OI, Ning JC-min, Touchette DR. Am J Health Syst Pharm. 2020;7:1778-1785.
Drug shortages are an ongoing threat to safe patient care. This commentary discusses the impact of COVID-19 on medication supply and demand, and the resulting drug shortages. The authors provide several recommendations for reducing future drug shortages in times of crises, including increasing stockpiles and creating a critical drug list with potential substitutes.
Sage WM, Boothman RC, Gallagher TH. JAMA. 2020;324:1395-1396.
The COVID-19 pandemic has generated numerous concerns in the healthcare industry, one of which is the potential for significant malpractice claims. This article discusses the possibility of a medical malpractice crisis in response to poor outcomes associated with COVID-19 and suggests that the industry follow an alternate path away from tort reform and legal actions. Alternatives such as communication and resolution programs can focus on patient safety principles such as transparency, redesign of systems to reduce adverse events, and patient and family support that could prevent traditional legal actions.
Angeli F, Montefusco A. World Dev. 2020;136:105106.
This analysis addresses the challenges of policymaking in complex crises, such as the COVID-19 pandemic, and presents a roadmap for learning based on a flexible and adaptive approach, local solutions, international cooperation, and transparent dissemination of data.  
Klest B, Smith CP, May C, et al. Psychol Trauma. 2020;12:S159-S161.
Institutional betrayal occurs when a patient (or other individual) experiences a harm and the (health) systems compound that harm by failing to support or believe the patient. The authors of this commentary reflect on institutional betrayal during the COVID-19 pandemic and discuss examples of betrayal experienced by patients, family members, and medical providers.
Stall NM, Jones A, Brown KA, et al. CMAJ. 2020;192:e946-e955 .
The authors conducted a retrospective study of all long-term care facilities in Ontario, Canada, to explore the association between for-profit status and the risk of COVID-19 outbreaks and deaths between March 29 and May 20, 2020. Results indicate that, compared to nonprofit facilities, for-profit status is associated with the extent of an outbreak and the number of resident deaths but not with the likelihood of an outbreak.
He M, Li Y, Fang F. J Am Med Dir Assoc. 2020;21:905-908.
This study combined quality ratings from Nursing Home Compare with state-level data to examine the association between nursing home-reported quality and COVID-19 cases and deaths. After adjusting for nursing home size and the racial composition of the residents, results indicate that nursing homes with higher ratings were less likely to experience COVID-19 cases and deaths.

Miller EA, ed. J Aging Soc Policy. 2020;32(4-5):297-535.

The COVID-19 crisis has disproportionally impacted the lives of older adults, their caregivers, and the communities in which they live. This special issue includes articles examining topics such as the role of policies affecting this patient population, effective communication with older adults and concerns associated with long-term care facilities.    
Dzau VJ, Kirch D, Nasca TJ. N Engl J Med. 2020;383:513-515.
This commentary discusses the ongoing impact of COVID-19 on the physical, emotional, and mental health on the healthcare workforce and outlines five high-priority actions at the organizational- and national level to protect the health and wellbeing of the healthcare workforce during and after the pandemic.  
Bavel JJV, Baicker K, Boggio PS, et al. Nat Hum Behav. 2020;4:460-471.
Using a social and behavioral sciences perspective, the authors present insights for aligning behavior with recommendations from experts for managing the COVID-19 pandemic and its impact. Topics include threat perception, leadership, individual and collective interests, science communication, social context, and stress and coping.
Am Geriatr Soc. 2020;68:908-911.
This policy brief presents the American Geriatric Society’s recommendations for caring for patients with COVID-19 in nursing homes and long-term care facilities. Recommendations focus on the production and distribution of personal protective equipment (PPE), patient transfer between hospitals and nursing homes, public health planning, workforce issues, and payment and tax relief for nursing homes. The brief reflects federal guidance as of April 4, 2020.