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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...
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Guttman OT, Lazzara EH, Keebler JR, et al. J Patient Saf. 2021;17:e1465-e1471.
Communication errors in health care are a persistent challenge to patient safety. This commentary advocates for studying behavioral, cognitive, linguistic, environmental, and technological factors to help understand barriers to effective information exchange in health care. The authors suggest that approaches targeting each set of barriers be developed and embedded into learning activities to generate lasting improvements.
Desai R, Williams CE, Greene SB, et al. Am J Geriatr Pharmacother. 2011;9:413-22.
Scrutiny over the quality of care delivered in post-acute settings is catalyzing improvement initiatives for this emerging safety priority. Medication safety and fostering a safety culture are previously identified needs, but greater attention to ensure safer care transitions is a targeted goal. This study analyzed medication errors reported by North Carolina nursing homes to describe specific errors that occurred during patient transitions to nursing homes. Of the nearly 30,000 individual medication errors reported, 11% involved a care transition. Notably, the transition-related errors were also associated with higher odds of patient harm. Contributing factors to the transition-related reports included problems with staff communication, order transcription, medication availability, and pharmacy issues. The authors highlight the opportunities for medication safety during this high-risk transition period for patients.