The PSNet Collection

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.

Displaying 1 - 3 of 3 Results

Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them.

Save to Library

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

‘You’re going to release him when he was hurting himself?’

Save to Library

Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

Broken, fragmented health-care system failed daughter who died by suicide.

Save to Library

Klowak M. CBC News. March 9, 2020.

System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users