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Patient Safety Network

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 - 12 of 12 Results
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    • Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.
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    • Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

    Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.
    Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.
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    • Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

    Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.
    Saving Moms.
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    • Boswell B. KCET: April 2023.

    Increasing attention is being placed on addressing inequities in maternal health care. This video shares stories of mothers experiencing harm during pregnancy and steps being taken to minimize the impact of implicit biases and lack of access to care to generate improvement.
    Investigating the impact of structural racism on Black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity.
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    • Jeffers NK, Berger BO, Marea CX, et al. Soc Sci Med. 2023;317:115622.
    Structural racism contributes to high rates of severe maternal morbidity (SMM) experienced by Black patients. This study investigated specific measures of structural racism (incarceration inequality and racialized economic segregation) on Black SMM. In this sample of births from 2008-2011, racialized economic segregation was associated with SMM for black patients; however, incarceration inequality was not.
    The Lancet Commission on lessons for the future from the COVID-19 pandemic.
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    • Sachs JD, Karim SSA, Aknin L, et al. Lancet. 2022;400:1224-1280.
    COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.
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    Diagnostic Safety
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    • 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.
    The Uneven Burden of Maternal Mortality in the U.S.
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    • NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

    Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
    Final Report of the Ockenden Review.
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    • London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

    Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.
    A crisis within a crisis.
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    • Ellis NT, Broaddus A. CNN. August 25, 2021. 

    Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.
    How medical jargon can make COVID health disparities even worse.
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    • Kritz F. Health Shots. National Public Radio; May 24, 2021.

    Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.
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