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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 56 Results
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

Washington DC:  Department of Veterans Affairs, Office of Inspector General; May 10, 2023.  Report no. 22-01116-110.

Death of a patient by suicide is a sentinel event. This report examined one incident and identified care deficiencies associated with lack of mental health referrals and pain management follow-up. In addition, post-event process gaps occurred, impacting learning and resolution such as a delay in the inquiry launch, peer review, and clinical review of the incident. Claims that the facility purposely sought to hide information that the suicide happened were unsubstantiated.

Santhosh L, Cornell E, Rojas JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. AHRQ Publication No. 23-0040-1-EF.

Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.

Massachusetts Protection and Advocacy. Boston, MA:  Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232.

Care coordination failures reduce the effectiveness of communication, information transfer, and patient monitoring to the determent of safety. This report examines the current state of interfacility transfers in 45 veteran facilities to find that, while process requirements were basically met, improvements could be made to medication list transfer, nursing communication, and general service evaluation.
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.

Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease. Seven recommendations are included for improving abnormal test result communication and error management at the facility.

Washington, DC: VA Office of the Inspector General;  February 17, 2022. Report No. 21-01506-76.

Patient suicide is a reoccurring sentinel event that is a challenge for the veteran’s health care community. This report shares the results of 36 unplanned inspections at United States Veterans Affairs facilities. While the inspections found general guidance compliance to be in place, weaknesses in required patient follow-up, staff training and outreach activities were flagged as areas in need of targeted improvement to enhance patient safety.
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.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.

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. 

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.   
Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.
Project RED re-engineered discharge with the goal of reducing preventable readmissions. This report summarizes an Agency for Healthcare Research and Quality project to transfer the Project RED experience to the primary care environment. Areas of focus included enhancing the team leader role of primary care physicians in post-discharge care.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.
Systemic weaknesses challenge safe care in Veterans Affairs health systems facilities. This report analyzed a patient suicide at one medical center and determined contributors to the failure. This report shares recommendations to address deficiencies including improved communication across the care continuum and reliably acting on root cause analysis results.
Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020.
Drug shortages result from a variety of systemic failures. This report identifies market demands and financial factors that disrupt medication production. The materials recommend development of shared mental models on the causes of medication shortages and how they affect patients. Legislative and pharmaceutical industry-level quality improvement strategies designed to address systemic weaknesses are reviewed.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.

Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.