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.
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.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted investigations and describes strategies to improve maternal safety, including standardizing procedures and enhancing communication.
Scott J, Heavey E, Waring J, et al. BMJ Open. 2016;6:e011222.
Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.
Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
This article reports on the abduction of a newborn by an individual masquerading as a hospital employee. Infant abduction is one of the patient safety "never events" defined by the National Quality Forum.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Dublin: Irish Society for Quality and Safety in Healthcare; 2004.
This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.
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