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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 280 Results
Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.
Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.
Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-76007-471-5.
Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.
Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Perspective on Safety August 5, 2022

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.
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, collaborative initiatives, teamwork, and trigger tools.
Patient Safety Innovation May 26, 2021

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Calder LA, Perry J, Yan JW, et al. Ann Emerg Med. 2021;77:561-574.
Prior research has found that some patients may be at risk for adverse events after discharge from the emergency department (ED). This cohort study analyzed adverse events occurring among patients discharged from the ED with cardiovascular conditions and identified several opportunities for improving safe care, such as adherence to evidence-based clinical guidelines and strengthening dual diagnosis detection.
Richmond RT, McFadzean IJ, Vallabhaneni P. BMJ Open Qual. 2021;10:e001142.
Timely completion of discharge summaries can improve handoffs with outpatient physicians and ensure communication of potential patient safety problems. This quality improvement project used an established change model to improve the rate of discharge summary completed within 24 hours from less than 10%, to 84% within 2 months.
Muhrer JC. Nurs Pract. 2021;46:44-49.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery, some of which may negatively impact patient outcomes.The authors use a syndemic perspective to discuss existing challenges interfering with diagnosis (structural, socioeconomic, patient-related, and provider-related), how the COVID-19 pandemic has exacerbated those challenges, and strategies related to nurse practitioners and community health workers to improve diagnosis.  
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.  
Koo JK, Moyer L, Castello MA, et al. Pediatr Qual Saf. 2020;5:e329.
Children are highly vulnerable to safety risks associated with written handoffs. This article describes the impact of unit-wide implementation of a new handoff tool using electronic health record (EHR) auto-populated fields for pertinent neonatal intensive care unit (NICU) patient data. Handoff time remained the same, and the tool increased the accuracy of patient data included in handoffs and reduced the frequency of incorrect medications listing. 

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Pediatr Qual Saf. 2020;5:e323.
This article describes one pediatric hospital’s experience adapting and implementing the I-PASS handoff program for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff.  The project demonstrates that I-PASS can be successfully used across a hospital system in various settings to reduce handoff-related errors.