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 333 Results

Research from webAIRS incident reporting system.

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Anaesth Intensive Care. 2023;51(6):372-421.

Centralized de-identified reports of patient safety events serve a core purpose for learning and improvement. This article collection contains research drawn from the Australian/New Zealand webAIRS database. Data reviewed include cesarean and pediatric regional anesthesia incidents submitted to webAIRS over a 13-year period.

Technology, Education and Safety

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Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.

On Patient Safety.

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Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Perioperative Safety Culture: Principles, Practices, and Pragmatic Approaches.

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McEvoy MD, Abernathy JH, 3rd. Anesthesiol Clin. 2023;41(4):xvii-xix;693-886.

Organizational, unit, and team culture affect the safety of surgical care. This special issue examines overarching principles, common practices, and practical actions that support safe perioperative processes and settings. Topics discussed include team dynamics, operating room design, and high reliability.

Improving patient safety by shifting power from health professionals to patients.

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BMJ 2023(383):2219, 2278, 2319, 2331.

This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a new policy in the United Kingdom motivated by the death of a pediatric patient to sepsis and the systemic weaknesses contributing to the adverse outcome. The policy is intended to encourage patients and caregivers to request a second opinion if a patient’s health condition is deteriorating and they feel their concerns are not being taken seriously by the healthcare team. The articles discuss the importance effective communication between clinicians, caregivers, and patients, mitigating adverse impacts of hierarchies, and the role of patient and caregiver engagement in the design of safe healthcare systems.

Understanding And Addressing Pre-Hospital Diagnostic Delays.

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Health Affairs Forefront; May-September 2023.

Diagnostic delays stem from both human and process failures. This series of articles examines how strategies such as behavioral design, internet use, and prehospital practice play a role in the timing of diagnosis.

Complications and Errors in Periodontal and Implant Therapy.

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Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398.

Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.

2022 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2023;49(9):435-450.

The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his passing. This special issue highlights the efforts of the 2022 Eisenberg Award honorees and their impact on improving patient safety and quality. The 2022 award recipients coved here include Jason S. Adelman, MD, MS, and North American Partners in Anesthesia (NAPA).

Covering Health: Patient Safety.

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HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2023.

The role media plays in raising awareness of patient safety issues in a timely and appropriate manner is consequential. This series instructs writers to communicate on medical error and quality topics in a high-quality professional style with discernment of the content being reported. Series contributions include discussions on medical error statistics and outpatient surgery rankings.

Quality and Safety in Health Care.

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Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, six sigma, and high reliability organizations.

The Retrievals.

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Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

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ISMP Medication Safety Alert! Acute care edition. July 13, 2023;(4):1-3;July 27, 2023;(5):1-5.

Risk Evaluation and Mitigation Strategy (REMS) programs help to ensure the safe use of distinct medications through communication, patient information, and implementation support. Part I of this article series examines systemic barriers to the deployment of REMS as a strategy to decrease potential for drug-related harm and medication error. Part II looks at the processes that one health system used to implement REMS.

Perioperative Handoffs.

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Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special issue explores perioperative handoffs and strategies to improve them. Topics covered include information accuracy, teamwork science, and artificial intelligence.

Diagnostic Safety Issue Briefs.

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Rockville, MD: Agency for Healthcare Research and Quality; 2020-2023.

Diagnostic safety has increased its footprint in research, publication, and awareness efforts worldwide. This series of occasional publications introduces diagnostic process concerns and efforts to address them. Topics covered include clinical reasoning, decision making, and patient engagement.

Patient Safety/Quality Improvement Primer.

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Otolaryngol Head Neck Surg. 2018-2023.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2023 installment covers measurement.

Lessons for Work-Life Wellness in Academic Medicine: Parts 1-3.

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Kans J Med. 2023;June 2016:153-171.

The well-being of the healthcare workforce is known to impact care delivery. This article series draws from front-line scenarios to illustrate how a wide range or personal and professional challenges intersect to affect patient safety. Topics covered in the presented cases include work-life integration, gender discrimination and clinical mistakes.

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

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Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.

TQIP Mortality Reporting System Case Reports.

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ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.

Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pinpoint process changes and enhance learning. This case series shares analysis of adverse events submitted to a trauma center-focused reporting program as tools for improvement. The cases are freely available.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Ensuring competency and safety when onboarding newly hired professional staff.

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ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.

Psychological safety is required for clinicians to ask questions as they adjust to working in new teams and environments. Part 1 of this article examines the cultural qualities enabling safe onboarding of new practitioners that encourage asking for assistance when uncertainty arises. Recommendations to encourage new hire questioning include mentor programs and scheduled supervisor conversations. Part 2 discusses the role of simulation to build skills in new staff to ensure medication safety.

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