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 186 Results

CUSP Implementation Training.

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Armstrong Institute for Patient Safety and Quality.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held April 18-19, 2023.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 31 and February 2, 2023.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. January 12 - March 2, 2023.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

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WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Delayed Diagnosis of Mesenteric Ischemia

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WebM&M Case August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.

Hospital discharge and readmission.

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Alper E, O'Malley TA, Greenwald J. UpToDate. August 18, 2022.

This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

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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.

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

Resident-faculty overnight discrepancy rates as a function of number of consecutive nights during a week of night float.

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Peterson C, Moore M, Sarwani N, et al. Diagnosis (Berl). 2021;8:368-372.

Recent duty hour reforms are intended to improve patient safety and resident well-being. This study explored whether resident performance declines as a function of consecutive overnight shifts, but results indicate no significant trend in overnight report discrepancies between the night float resident and the daytime attending.

Delayed Breast Cancer Diagnosis: A False Sense of Security.

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WebM&M Case December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

A war on two fronts: cancer care in the time of COVID-19.

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Kutikov A, Weinberg DS, Edelman MJ, et al. Ann Intern Med. 2020;172:756-758.

Oncology patients, as with other patients with chronic health care needs, face numerous challenges during the COVID-19 pandemic. The authors discuss the need to balance delays in cancer diagnosis or treatment against the harm of COVID-19 exposure, how to mitigate the risk for significant care disruptions associated with social distancing and managing the allocation of limited healthcare resources during this unprecedented pandemic.

"Do You Want Everything Done?": Clarifying Code Status

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WebM&M Case December 18, 2019

A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.

How implicit bias harms patient care.

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Bendix J. Med Econ. November 25, 2019;96(23);10-14.

Implicit biases can compromise decision making due to the effect they can have on heuristics, communication and patient/physician communication. This article shares reasons for these biases and shares tactics to minimize their impacts which include being mindful of biases and a personalized approach to patients.

The Safety Challenges of Supervision and Night Coverage in Academic Residency

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WebM&M Case October 30, 2019

An intern night float, called in on jeopardy from an outside institution for an intern who was ill, was paged to the bedside of an unstable patient to assess his condition. In the electronic health record, the intern checked the code status and clinical information, but the signout did not specify the patient’s goals of care nor what course of action to take should the patient worsen. Although the patient was listed as full code and the intern attempted to reach both the rapid response team and the senior resident, she was not aware the pager numbers were incorrect.

A randomized experimental study to assess the effect of language on medical students' anxiety due to uncertainty.

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Simpkin AL, Murphy Z, Armstrong KA. Diagnosis (Berl). 2019;6:269-276.

Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.

Safety of care by caregivers of cancer patients.

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Given BA. Semin Oncol Nurs. 2019;35:374-379.

Cancer patients often rely on family members or paid caregivers to assist with care maintenance at home, such as taking medications and mobility support. This review highlights common safety gaps in home cancer care. The authors suggest that nurses can help assess caregiver knowledge and provide education to address safety issues.

Renal Failure Due to Benign Prostatic Hyperplasia

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WebM&M Case August 10, 2019

Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so).

Teamwork Toolkit.

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Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019.

Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.

Patient and physician experience with interhospital transfer: a qualitative study.

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Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.

This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.

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.

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