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 38 Results

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Curated Libraries

Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

Resilient Healthcare and the Safety-I and Safety-II Frameworks

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Perspective on Safety December 14, 2022

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

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.

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.

Patient Safety in the Ambulatory Care Setting

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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.

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

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Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.

Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.

Curated Libraries

Maternal Safety

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.

Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.

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Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18:40-45.

Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

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Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.

Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.

Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis.

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Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.

Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.

Patient Safety 101

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Patient Safety Primer September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Patient Safety.

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National Pharmacy Association; NPA.

This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.

Understanding test results follow-up in the ambulatory setting: analysis of multiple perspectives.

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Ai A, Desai S, Shellman A, et al. Jt Comm J Qual Patient Saf. 2018;44:674-682.

This study examined ambulatory follow-up of test results by aggregating multiple types of data—national surveys on safety culture and patient satisfaction; patient complaints; safety reports; and electronic health record audits of provider response times. Researchers found an association between quicker response time for test results and higher patient satisfaction. They conclude that merging these disparate data sources can uncover new levers to improve patient safety.

Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.

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Arbaje AI, Hughes A, Werner N, et al. BMJ Qual Saf. 2019;28:111-120.

Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.

Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines.

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Grant S, Guthrie B. Soc Sci Med. 2018;203:43-50.

Past studies have explored the impact of nurse and clinician workload on the quality of care. In this study, researchers examined how general practitioners and administrative staff across eight United Kingdom practices work together to fill prescription requests and manage test results.

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

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Grant S, Checkland K, Bowie P, et al. Implement Sci. 2017;12:56.

Test result management is a critical aspect of ambulatory patient safety. This direct observation study identified highly variable strategies across outpatient practices with different vulnerabilities. These results underscore the need to develop interventions to enhance management of test results.

Health literacy and patient safety events.

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Gardner LA. PA-PSRS Patient Saf Advis. 2016;13:58-65.

Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.

Root cause analyses of suicides of mental health clients.

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Gillies D, Chicop D, O'Halloran P. Crisis. 2015;36:316-324.

This study used root cause analysis to identify underlying causes of suicide among mental health service clients. Researchers found that most patients had denied suicidal ideation and had missed follow-up in their mental health care. Their results underscore the challenge of preventing suicide in patients with mental illness.

Characteristics associated with postdischarge medication errors.

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Mixon A, Myers AP, Leak CL, et al. Mayo Clin Proc. 2014;89:1042-51.

Postdischarge medication errors occurred in nearly half of patients hospitalized for acute coronary syndromes or congestive heart failure, with errors more likely to occur in patients with limited health literacy or numeracy.

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