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 37 Results

Maryland Hospital Patient Safety Program Annual Report.

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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.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action.

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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.

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

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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.

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Diagnostic Safety

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.

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

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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.

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Maternal Safety

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.

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

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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.

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

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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.

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

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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.

The Diagnosis of Ectopic Pregnancy.

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Farnborough, UK: Healthcare Safety Investigation Branch; March 2020.

Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a delayed diagnosis ectopic pregnancy incident and found that referral and discharge missteps contributed to the error.

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

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Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.

Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.

Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

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Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.

Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.

Nurse Staffing Levels, Missed Vital Signs and Mortality in Hospitals: Retrospective Longitudinal Observational Study.

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Griffiths P, Ball JE, Bloor K, et al. Southampton, UK: NIHR Journals Library; 2018.

Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

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London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.

Patients with mental health conditions face particular safety challenges. This report describes incidents involving patients with eating disorders who experienced harm while receiving care in National Health Service organizations. Factors that contributed to the failures included poor care coordination, premature discharge, and lack of monitoring. The report discusses gaps in the investigations of these patient deaths and outlines areas of improvement.

The Joint Commission Big Book of Checklists. 2nd Edition.

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Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598.

Checklists are a widely accepted strategy to improve communication and standardize processes to support reliability. This publication includes information on what makes a checklist useful and provides numerous checklist templates that focus on tasks in areas such as medication management, performance improvement, and infection control that can be implemented in various settings.

Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.

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Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

Safely Home: What Happens When People Leave Hospital Care Settings?

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London, UK: Healthwatch England; July 2015.

Discharges are vulnerable periods for patients, often due to miscommunication, delays, and lack of patient-centeredness. This report reviews experiences of more than 3000 patients in England regarding the effects of poor discharge. The results, which focus on older and homeless patients (given the increased potential for negative clinical consequences in these populations), highlights several practices that can improve the safety of hospital discharges.

Field Guide to Collaborative Care: Implementing the Future of Health Care.

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Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290.

This online resource provides instructions and templates for implementing team-based, collaborative care. This group's collaborative care model has received a John M. Eisenberg Award for contributions to patient safety.

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