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 82 Results

‘They can’t ignore us any more’: five women on long Covid and medical misogyny.

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Lu D. The Guardian. October 18, 2022.

Disrespect for women around the world is known to occur in health care that contributes to diagnostic delay and lack of trust in the system. This news article describes challenges met by 5 women patients seeking diagnosis and treatment for long COVID.

People of color with long COVID face uphill battle to be heard.

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Farah T. Scientific American. September 22, 2022.

Gaslighting women and patients of color is known to occur in health care for both common and emerging conditions. This news article describes challenges met by a patient seeking diagnosis and treatment for long COVID.

Dying for Care.

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Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

Nowhere is safe: record number of patients contracted Covid in the hospital in January.

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Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

Start the year off right by addressing these top 10 medication safety concerns from 2021.

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ISMP Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.

COVID Risk In Hospitals.

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Weber L, Jewett C. Kaiser Health News. 2021-2022.

The infectious nature of COVID continues to impact the safety of hospitalized patients. This article series examines factors contributing to hospital-acquired COVID-19 infection that include weaknesses in oversight, patient legal protections, and documentation.

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

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Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares errors reported to the ISMP Vaccine Errors Reporting Program and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

The less-discussed consequence of healthcare's labor shortage.

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Bean M, Masson G. Becker's Hospital Review. October 4, 2021.

Staffing shortages can impact the safety of care by enabling burnout, care omission, and staff attrition. This article discusses how the COVID-19 pandemic has necessitated an examination of how staffing challenges affect areas such as diagnosis, infection control, and organizational patient safety focus.

How to seek care for non-covid health issues during the pandemic, and why you shouldn’t delay.

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Bever L, Chiu A. Washington Post. September 16, 2021.

Throughout the COVID pandemic, patients have shown reluctance to seek medical care, which contributes to delayed diagnoses and treatments for non-COVID conditions. This news story suggests actions for patients to take to keep themselves safe from harm while accessing care during uncertain times.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

'There is a real cost’: as Covid shows, barring bedside visitors from ICU deprives patients of the best care.

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Renault M. STAT. July 28, 2021.

Care and safety concerns for patients, families, and clinicians continue to be challenged by COVID-19. This article discusses the unintended consequences of isolation practices during the pandemic as a contributor to patient harm due to resultant family support barriers and loneliness they caused.

Machine learning is booming in medicine. It’s also facing a credibility crisis.

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Ross C. STAT. June 2, 2021.

Artificial intelligence and machine learning are often promoted as tools with impressive potential for generating rapid improvements in healthcare decision making. This news story highlights how underlying problems and testing failures limit the trustworthiness of conclusions drawn by the systems.

How medical jargon can make COVID health disparities even worse.

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Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

A crisis of undiagnosed cancers is emerging in the pandemic’s second year.

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Eldeib D. ProPublica. May 4, 2021.

Concerns continue to emerge regarding the effect of the COVID-19 pandemic has had on the timely diagnosis of cancer. This story highlights the impact of patient inability or unwillingness to schedule annual screenings, physician visits and treatment of chronic conditions and primary contributors to the problem.

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

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ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5.

Process change can introduce opportunities for error into established practice. This article builds on results of an earlier survey to expand the record on the types of COVID vaccine errors such as wrong patient age, dilution problems, and vaccine card confusion.

Doctors were sure they had Covid-19. The reality was worse.

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Browne G. Wired UK. April 23 2021

Diagnosis can be challenged by cognitive bias, fatigue, and lack of knowledge. This article discusses how availability biases, uncertainty, and other decision-making missteps effected diagnosis of non-COVID disease early in the pandemic.

Pandemic imperiled non-English speakers more than others.

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Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

COVID-19 dominates annual list of patient safety concerns.

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Brooks M. Medscape Medical News. March 15, 2021.

Safe care is influenced by both global and local changes in the environment. This news story summarizes a prioritized list of patient safety concerns--many of which were heightened due to the COVID-19 pandemic. Inequities due to ethnicity, lack of emergency readiness and ineffective pandemic readiness are highlighted.

5 pandemic mistakes we keep repeating. We can learn from our failures.

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Zeynep Tufekci. The Atlantic. February 26, 2021

Failures in communication have impacts on patients, teams, organizations and society. This article discusses five weaknesses in pandemic messaging that were counterproductive including use of shaming instead of empathy to engage the public, lack of detail on suggested strategies and insufficient advice to support public adoption of harm reduction activities.

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