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 - 18 of 18 Results

Top 10 Patient Safety Concerns.

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Plymouth Meeting, PA: ECRI; March 2023.

The global COVID-19 pandemic continues to exacerbate weaknesses in care that can contribute to harm. ECRI presents the top ten patient concerns for 2023, including pediatric mental health care, workplace violence, care coordination, and patient medication list mistakes.

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

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Washington, DC: United States Government Accountability Office; Publication GAO-22-105133. September 14, 2022.

COVID-19 generated unprecedented challenges for the nursing home industry, revealing and amplifying process, staffing, trust, and infection control weaknesses to the detriment of care. This report analyzed current infection protection actions in long-term care. A primary improvement conclusion drawn from the examination is to strengthen the role of infection control professionals.

Implication of the COVID-19 Pandemic for Patient Safety: A Rapid Review.

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Integrated Health Services. Geneva, Switzerland: World Health Organization; 2022. ISBN: 9789240055094.

The COVID-19 pandemic created new risks and acerbated existing risks across all areas of health care practice that challenge patient safety. This review examines how COVID impacted diagnostic, treatment, and care procedures in a systemic context.

Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.

The COVID-19 crisis affected most health care processes, including diagnosis. This report recaps a session examining impacts of the pandemic on diagnostic approaches, inequities, and innovations that may inform future diagnostic improvement efforts.

Caring for Those Who Care: Guide for the Development and Implementation of Occupational Health and Safety Programmes for Health Workers.

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Geneva, Switzerland: World Health Organization and International Labour Organization; 2022. ISBN 9789240040779.

Workforce well-being emerged as a key component of patient safety during the COVID-19 crisis. This report supplies international perspectives for informing the establishment of national regulations and organization-based programs to strengthen efforts aiming to develop health industry workforce health and safety strategies.

NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021.

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Rockville, MD: Agency for Healthcare Research and Quality; November 2021. AHRQ Pub. No. 22-0005.

This analysis of reports submitted by Patient Safety Organizations during the early months of the COVID pandemic found that patients testing positive for COVID-19 or being investigated for carrying the virus was the most frequently reported patient safety concern (26.6%). In addition, patients and staff being exposed to individuals who had tested positive for COVID-19 was identified as a patient safety issue in 18.2% of the records analyzed.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics?

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Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.

Improving Telediagnosis: A Call to Action.

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Evanston, IL: Society to Improve Diagnosis in Medicine; March 2021.

Telehealth is commonly used to deliver health care, yet its safety across the continuum has yet to be determined. This report highlights perspectives on the potential of telediagnosis and examines its reach, effectiveness, adoption, implementation, and maintenance, to inform actions to ensure its safe use.

Communication and Transparency as a Means to Strengthening Workplace Culture During COVID-19.

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Nadkarni A, Levy-Carrick NC, Kroll DS, et al. National Academy of Medicine; 2021.

Communication within teams is central to safe care delivery, crisis management, and staff well-being. This report shares the experience of one hospital that used technology to enhance information-sharing as a strategy to reduce clinician burnout in times of uncertainty and crisis.

Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0

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La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.

Health Worker Safety: A Priority for Patient Safety.

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Geneva, Switzerland: World Health Organization; September 17, 2020.

The intersection of worker well-being and safety with patient harm prevention has become apparent due to COVID-19. This report discusses five areas of importance in motivating lasting change in health care environments to support the safety of the work force. It highlights policy and strategy alignment, occupational considerations, violence reduction, psychological concerns, and physiological harms as essential elements of a robust approach to workforce safety improvement.

Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic.

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London, UK: General Medical Council; September 14, 2020.

Physician caregiving effectiveness can be tested during crisis situations. This guidance shares recommendations for leaders assessing complaints against physicians during the COVID-19 pandemic to consider extenuating circumstances when determining next steps in managing the response to poor care delivery.

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

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The COVID-19 pandemic has revealed weaknesses in health care systems worldwide that have affected drug distribution, worker safety and health equity. This report provides a stakeholder analysis of societal conditions affecting patients with coronavirus in the United Kingdom. The authors conclude that racism and discrimination must be considered to correct inequities that impact safe care for Black Asian Minority Ethnic (BAME) patients to effectively respond to COVID-19.

Person-Centered Guidelines for Preserving Family Presence in Challenging Times.

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Derby, CT: Planetree; 2020.

Families have an important role in keeping patients safe. This book provides a set of patient-centered recommendations that outline steps to address the social and emotional individual needs of patients with organizational requirements to keep patients clinically safe.

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

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Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-576R.

This US Government Accountability Office (GAO) report highlights the chronic shortfalls in nursing home infection control programs. The GAO analyzed survey data from the Centers for Medicare & Medicaid Services (CMS) and found 82% (13,299) of nursing homes surveyed were cited in one or more years between 2013-2017 and in each individual year, 40% of nursing homes had infection control and prevention deficiencies that continued through 2018 and 2019. While the majority of the citations did not indicate harm to nursing home residents and were rarely associated with enforcement actions, the GAO intends to examine CMS oversight of infection and control in the near future. In light of the COVID-19 pandemic, these findings are particularly concerning.

Crisis Standards of Care: Ten Years of Successes and Challenges–Proceedings of a Workshop.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC; The National Academies Press: 2020. ISBN 9780309676250.

Patient safety is challenged during public health emergencies. This report examines a 10-year initiative to develop crisis preparedness standards. The material covers how to proactively apply the program’s experience to assess legal and ethical considerations, learn from federal and state initiatives, address challenges and design steps to continue progress.

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

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Washington DC: Office of the Inspector General; April 3, 2020. Report no. OEI-06-20-00300.

Frontline perspectives provide organizations with knowledge to inform improvement. This report summarizes survey results exploring organizational strategies to address workforce and patient safety challenges stemming from the current COVID-19 pandemic response.

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