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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 - 17 of 17 Results

Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

Clark C. MedPage Today. August 4. 

Consistent policy supporting transparency of hospital safety records is important for patients as they make provider choices. This article highlights a shift made to retain reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP) that had been threatened due to the influence of the COVID pandemic on data integrity.

Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.
Yong E. The Atlantic. 2020;September.
This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

Gabler E. New York Times. May 31, 2019.

Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.