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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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Displaying 1 - 20 of 65 Results

West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.
Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.
Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.
Hilario C, Louie-Poon S, Taylor M, et al. Int J Soc Determinants Health Health Serv. 2023;53:343-353.
Structural racism is increasingly recognized as a social determinant of health. This systematic review identified 13 articles on the impact of racism on racialized adolescents. Most articles focused on the impact of racism on healthcare access and utilization, and in general or mental health care. Research into multiple forms of racism (i.e., institutional, interpersonal, internalized) and development and incorporation of robust measures of racism is needed to advance the field.
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
The TeamSTEPPS® program was developed to support effective communication and teamwork in health care. The curriculum offers training for participants to implement TeamSTEPPS® in their organizations. The 3.0 version of the material has an increased focus on patient engagement and a broader range of clinical, administrative and leadership roles. The course includes updated evidence reviews, trainer guidance, measurement tools, a pocket guide quick reference to keyTeamSTEPPS® concepts and tools, and new patient videos.
Ames SG, Delaney RK, Houtrow AJ, et al. Pediatrics. 2023;152:e2022060975.
People with disabilities encounter a variety of system- and clinician-level barriers when seeking healthcare. This study reports on disability-based discrimination faced by children with medical complexities and their caregivers. Apathy, clinician assumptions, and lack of clinician knowledge were identified as drivers of discrimination resulting in limited accessibility, substandard care, and dehumanization.
Mirarchi FL, Pope TM. J Patient Saf. 2023;19:289-292.
Providing treatment that is discordant with patients’ preferences for end-of-life care can lead to unnecessary or unwanted treatment. This article summarizes the incidence of treatment discordant with their Portable Orders for Life Sustaining Treatment (POLST) and advanced directives (ADs) and tools for use by clinicians and patients and family members to promote concordant care. A previous PSNet WebM&M Spotlight Case discusses the importance of advanced care planning and the consequences of inadequate communication and planning for end-of-life care.
AHA Team Training. September 7 - November 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. 
Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.
Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.
Washington A, Randall J. J Racial Ethn Health Disparities. 2023;10:883-891.
Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.
Hoffmann DE, Fillingim RB, Veasley C. J Law Med Ethics. 2022;50:519-541.
Women’s pain has been underestimated compared to men’s pain, and treatments differ based on gender. This commentary revisits the findings from the 2001 article The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. The authors state progress has been made in the past 20 years, but disparities still exist. Additional research is needed, particularly into chronic pain conditions that are more common in women.
Curated Libraries
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. ...
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Curated Libraries
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.
Stayt LC, Merriman C, Bench S, et al. J Adv Nurs. 2022;78:3371-3384.
The COVID-19 pandemic dramatically changed healthcare delivery across all settings. This qualitative study explored perceptions of patient safety in intensive care among nurses redeployed to intensive care settings during the pandemic. Nurses reported increases in patient safety risks during the pandemic, which were largely attributed to changes in nursing skill mix and poor continuity of care.
WebM&M Case March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

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, collaborative initiatives, teamwork, and trigger tools.

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

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. 

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

 

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed.