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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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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...
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. BMJ Qual Saf. 2021;30:697-705.
Checklists are commonly used in surgical and critical care settings to improve patient safety. This multisite study simulation study found that checklists can improve local resuscitation teams’ management of medical crises such as anaphylactic shock and septic shock in emergency departments.
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  
Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.  
Patient Safety Primer July 30, 2020
This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.
Fitzsimons J. Int J Qual Health Care. 2021;33:mzaa051.
This article discusses the importance of leveraging quality improvement and patient safety science in acute and emergency situations. Methods and tools such as rapid learning cycles, huddles, team-based approaches, and debriefing and their applications to the COVID-19 pandemic are discussed.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Estock JL, Pham I-T, Curinga HK, et al. Jt Comm J Qual Patient Saf. 2018;44:683-694.
Hypoglycemia can lead to catastrophic adverse events if not acted upon quickly. Researchers tested an easier-to-read display for a glucometer commonly used in hospitals. This human factors engineering approach enabled nurses in simulations to more accurately interpret and respond to low blood sugar readings.
Center for Health Design.
Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collection includes an assessment and interactive tools to test ideas for improvement.
Murray P. Washington, DC; Senate Health, Education, Labor, and Pensions Committee; 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Perspective on Safety August 1, 2015
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Hamilton DK, Stichler JF, eds. HERD. 2013;7(suppl):1-154.
Articles in this special supplement draw from AHRQ-funded efforts to reveal how designing around space and human factors can reduce the spread of health care–associated infections. Design interventions described include air filtration systems, decontamination of water sources, and antimicrobial surfaces.
Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD; National Institutes of Health; NIH.
This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units. This funding cycle has an expiration due date of September 8, 2021.