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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 62 Results

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019.

Central line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are a persistent challenge for health care safety. This report shares the results of a 6-cohort initiative to reduce CLABSI and/or CAUTI infection rates in adult critical care. Recommendations for collaborative implementation success are included.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.

Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.

Challenges beset safe care delivery for indigenous peoples. This report examines factors contributing to adverse events in this patient population. Recommendations for improvement include an emphasis on harm monitoring and incident reporting. A related report examines the lack of application of maternity best practices in the Indian Health Service.

de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.

The assessment of patient safety culture is critical for understanding the success of organizational efforts to provide a foundation for improvement work. This report examines tools used in a variety of countries to assess culture and underscores the value that the assessment of culture can bring to understanding problems and implementing sustainable improvements.

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.

Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

Wrong route medication administration is a never event. This report examined the context, organizational and human factors that contributed to the accidental intravenous administration of an oral solution into a pediatric patient. Safety recommendations include medication safety training, standardized administration processes, and elevation of the medication safety officer role. 

Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.

The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Mayor S, Baines E, Vincent C, et al.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Wright J, Lawton R, O’Hara J, et al. National Institute for Health Research; 2016:1-296.
Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.