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 266 Results

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available.

National Patient Safety Goals.

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The Joint Commission.

The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

MHA and MHA Keystone Center Annual Reports.

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Okemos, MI: Michigan Health & Hospital Association.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. The achievements noted in the 2022-2023 data review include reduction of MHA Keystone Center PSO members have significantly reduced both fall and blood or blood product events reported to the state patient safety organization reporting system. Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal health.

Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error.

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Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. Publication No. 23-0040-6-EF.

Psychological safety to report errors stems from a robust safety culture. This issue brief examines how these two concepts intersect to enhance the self-reporting of diagnostic errors to facilitate organizational learning from mistakes.

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2023.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety.

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James C, Singh K, Valley TS, et al. Rockville, MD; Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0040-4-EF.

As artificial intelligence (AI) and machine learning (ML) become established in health care, it is critical for clinicians and patients to effectively collaborate to use AI safely. This Issue Brief adds to a series of diagnostic-focused reports and presents a framework to guide patients and clinicians on working as team members when using AI and ML to make diagnostic decisions.

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

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Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).

Adverse Events Toolkit: Medical Record Review Methodology.

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Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00030.

Medical record review is a primary tactic to identify health care actions that contribute to patient harm. This report discusses the review process used in the 2018 report Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm to illustrate a successful review process for use by clinicians and researchers. It is a companion toolkit to the Clinical Guidance for Identifying Harm publication.

Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades?

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Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.

Adverse events in patients of color continue to be connected with systematic racism and biases. This report summarizes the distribution of patient safety events among Black and Hispanic patients across 2,019 Leapfrog patient safety graded hospitals and found that they experience adverse surgical events at a higher level than white patients.

Challenge Competition: Impact of Patient Safety Tools.

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Agency for Healthcare Research and Quality, Rockville, MD. 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2023.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2022 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional sections cover educational, publication, and learning management system efforts.

Surveys on Patient Safety Culture.

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Rockville MD: Agency for Healthcare Research and Quality; 2020.

Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

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Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Pub. No.22(23)-0065-1.

Research has shown that involving patients, their families and caregivers, in the planning, delivery, and evaluation of their healthcare can improve safety and quality. This collection of AHRQ-funded work includes summaries of 53 projects since 2000 that contributed to environments in which patients, families, and healthcare professionals work together to improve the quality and safety of care. Efforts highlighted include those involving patients and families in activities designed to report and ultimately prevent medical errors and near misses.

National Safety Standards for Invasive Procedures (NatSSIPs2).

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Centre for Perioperative Care. London, UK; January 2023.

Patients face risks when undergoing surgery. This revised guidance provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures. The report is centered on areas of effort targeting both organizational and process-level actions.

Action Planning Tool for the AHRQ Surveys on Patient Safety Culture.

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Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011.

Improving the culture of safety within health care is an essential component of preventing or reducing errors. Designed for users of the AHRQ safety culture surveys, this updated tool will help organizations develop an action plan and proactively discuss potential barriers to safety culture improvement efforts and how to address them. The revision is structured around a 3-step process that focuses on areas to improve, initiative planning, and plan communication. The kit now includes an action plan template.

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

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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.

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