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 765 Results

Patient Safety Learning Laboratories: Advancing Patient Safety through Design, Systems Engineering, and Health Services Research (R18 Clinical Trial Optional).

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Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.

This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 25, 2023.

AHRQ Safety Program for Telemedicine.

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Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023.

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

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Agency for Healthcare Research and Quality. January 24, 2023, 1:00 – 2:00 PM (eastern).

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session will introduce the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey will be shared.

Diagnostic Errors in the Emergency Department: a Systematic Review.

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Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures.

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

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Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments is January 26, 2023.

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals.

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Hare R, Tyler ER, Tapia A, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 22(23)-0008.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The SOPS Workplace Safety Supplemental Item Set for Hospitals was designed for use in conjunction with the AHRQ Hospital Survey to help hospitals assess the extent to which their organization’s culture supports workplace safety for providers and staff. This data analysis found “Protection From Workplace Hazards” as the highest-scoring composite measure and “Addressing Workplace Aggression From Patients or Visitors” as the lowest-scoring composite measure. An average of 34% of healthcare providers and staff experienced symptoms of “Work Stress/Burnout” which represents a 4-percentage point increase from the 2021 pilot study results.

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.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022.

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Dowell D, Ragan KR, Jones CM, et al. MMWR Recomm Rep. 2022;71:1-95.

In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for safe opioid prescribing for chronic pain. Based on an updated evidence review, the CDC has revised the guidelines and released the Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022, include recommendations for outpatient acute, subacute, and chronic opioid use. The twelve recommendations fall into four broad categories: determining whether or not to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use. The CDC will update and develop tools and resources to support dissemination of these guidelines. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care, or for patients in the emergency department or admitted to the hospital.

Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2022 User Database Report.

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Hare R, Tapia A, Tyler ER, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication No. 22(23)-0066.

Instituting a culture of safety is fundamental to ensuring patient and staff safety. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey is a validated survey that has been widely used to assess patient safety culture since 2004. The 2022 report includes data from 400 hospitals. The highest “percent positive” composite measure scores included both effective teamwork and supervisor, manager, or clinical leader support for suggestions for improving patient safety, and addressing patient safety concerns. Overall, when asked to rate their unit/work area on patient safety, 67 percent of respondents rated their unit/work area as “Excellent” or “Very Good.”

Diagnostic Safety Centers of Excellence.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Diagnostic improvement engages a variety of activities to achieve excellence. This announcement highlights ten organizations AHRQ funded to establish Diagnostic Safety Centers of Excellence. Their focused efforts will work to improve diagnostic safety and quality. Areas of project focus include use of information technology to improve diagnostic accuracy and teamwork as an improvement strategy.

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders.

The National Healthcare System Action Alliance to Advance Patient Safety.

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US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.

Toolkit To Improve Antibiotic Use in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.

Calibrate Dx: A Resource to Improve Diagnostic Decisions.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-0047-2-EF.

Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians, yet physicians rarely receive feedback on their actions to enhance diagnostic decision making. This publication provides clinicians with tools to assess and calibrate diagnostic performance in support of individual learning and improvement.

Golden State Medical Supply, Inc. Issues a Voluntary Nationwide Recall of Atenolol 25 mg Tablets and Clopidogrel 75 mg Tablets Due to a Label Mix-up.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.

Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.

Understanding SOPS Surveys--A Quick Primer for New Users.

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Rockville, MD: Agency for Healthcare Research and Quality. November 7, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts.

How To Create a My Medicines List.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

This tool provides a printable template and step-by-step instructions for patients to create a visual reference for keeping track of medications.

Curated Libraries

Diagnostic Safety

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.

Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18).

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Rockville, MD: Agency for Healthcare Research and Quality; September 28, 2022. PA-20-028.

Medication errors are a consistent challenge in health care. This funding announcement seeks applications that focus on standardization and process enhancements to reduce care delivery factors that decrease the safety of medication use. This funding announcement will expire January 27, 2022.

Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators.

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Tran AK, Calabrese M, Quatrara B, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-4-EF.

Nurses are underutilized as members of the diagnostic team. This publication examines the role of nursing educators and leaders to enhance the participation of nurses in diagnostic processes. It shares strategies for improving diagnosis through nurse engagement in the process. This issue brief is part of a series on diagnostic safety.

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