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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 37 Results

Guiding Principles to Achieve Continuity in Medication Management.

Save to Library

Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-76007-471-5.

Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.

Curated Libraries

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.

Error Reduction and Prevention in Surgical Pathology, Second Edition.

Save to Library

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.

Medication Safety in Key Action Areas.

Save to Library

Geneva, Switzerland: World Health Organization; 2019.

Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.

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

Save to Library

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.

Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions.

Save to Library

Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.

Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.

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

Save to Library

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.

Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings.

Save to Library

Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.

Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.

New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians.

Save to Library

Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014.

Poor communication can contribute to medical error, but incident analysis often fails to identify particular elements of communication associated with the error. This publication discusses factors that influence communication in the medical care process and uses case studies to illustrate how effective communication can help prevent and address close calls and adverse events.

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

Save to Library

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.

Save to Library

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.

Patient and Family Engagement in Primary Care: Case Studies.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

Save to Library

Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.

The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.

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

Save to Library

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.

Implications of Health Literacy for Public Health: Workshop Summary.

Save to Library

Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.

Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.

An Avoidable Death of a Three-year-old Child from Sepsis.

Save to Library

London, UK: Parliamentary and Health Service Ombudsman; June 2014.

This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.

There and Home Again, Safely.

Save to Library

Sokol PE, Wynia MK; AMA Expert Panel on Care Transitions. Chicago, IL: American Medical Association; February 2013.

This report proposes five responsibilities for ambulatory care practices to ensure safe care transitions and describes principles to guide staff in performing these tasks.

DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.

Save to Library

Washington, DC: United States Government Accountability Office; November 2, 2012. Publication GAO-13-26.

This government report reveals the need for a policy to ensure that veterans' medication needs are safely managed during transitions between health care providers.

Order from Chaos: Accelerating Care Integration.

Save to Library

Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.

This report discusses the need for improved coordination and integration in patient care to reduce preventable errors.

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

Save to Library

Cambridge, MA: Institute for Healthcare Improvement; June 2012.

This series, developed in conjunction with the STAAR initiative, provides tactics and resources to improve transitions across various care settings.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users