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.
Skin condition diagnosis is a visual activity that is vulnerable to error. This article highlights how conditions such as psoriasis and skin cancer can be misdiagnosed. The piece shares recommendations for patients to obtain an accurate diagnosis such as seeking a second opinion and preparing for appointments with notes and questions.
A blameless approach to error and near miss reporting is foundational to the success of the effort. This article discusses one organization’s persistent challenge with shifting reporting to align with a safety culture. The author describes the importance of staff education and leadership to support the focus of reporting initiatives on the system rather than individuals when failures occur.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns.
Klenklen J. Patient Saf Qual HCare. December 19, 2019.
High reliability organizations consistently examine what goes wrong and remain aware that failure can happen at any time. This article discusses a learning model built upon event definition, rapid contributing factor identification, system-focused communication, and standardized learning to facilitate organizational learning from sentinel events.
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