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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 30 Results
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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.

Feibel C. Consider This. National Public Radio. August 3, 2022. 

Maternal complications risk the health of both mothers and babies, and a variety of circumstances create challenges to this complex care process. This article describes delays in care for a pregnant patient due to legal and policy concerns that threatened the life of the mother.

Pasztor A. Wall Street Journal. September 2, 2021.

Aviation continues to serve as an exemplar for healthcare safety efforts. This story highlights work toward the development of a National Patient Safety Board for medicine to establish a neutral centralized body to examine errors and share improvements driven by a robust self-reporting culture similar to that in commercial aviation.

Wamsley L. National Public Radio and WBUR. December 7, 2020.

Testing for COVID-19 is a core public safety strategy for pandemic management. This news story discusses how a lack of health care workers’ virus status knowledge could contribute to spread. Barriers inherent to a universal testing strategy include operational challenges, patient testing volume, and availability of health care workers to provide care during the pandemic should clinicians test positive.

Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.   

Mann B. All Things Considered. National Public Radio. October 5, 2020.

Clinicians are susceptible for medication misuse due to stress, fatigue, or arrogance. This news article discusses how drug diversion should signal behaviors that can harm patients, the clinicians themselves, and the organizations they work for. Reporting gaps contribute to the perpetuation of the problem. 

Booker C. PBSNewshour Weekend. May 10, 2020.

Built environment characteristics can contribute to the spread of infection. This news segment discusses design approaches one hospital implemented to reduce the potential for COVID-19 transmission to both patients and clinicians in their organization. Prevention tactics highlighted include placement of equipment and creation of negative pressure isolation rooms.

Shaprio J. National Public Radio. April 15, 2020.

Access to care has been strained by the COVID-19 pandemic. This radio segment discusses how implicit biases can affect care of patients with disabilities. It highlights how preconceptions about this patient population could limit their access to treatments should they become ill.

Garcia-Navarro L. Weekend Edition Sunday. National Public Radio. December 1, 2019.

Financial harms occur in health care due to a variety of factors such as overdiagnosis and ineffective billing practices. This radio interview highlights physician concerns over a hospital policy to sue patients and families for unpaid bills. Physicians at the organization have stated the practice works against their commitment to keeping patients from harm.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.
Maternal death is a sentinel event. This news audio segment reports on childbirth-related death in the United States and firsthand accounts of complications associated with childbirth, such as infection. The interview also discusses how misdiagnosis contributes to the severity of problems. This piece is part of an ongoing series on the safety of maternal care.
CDC; Centers for Disease Control and Prevention.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
Rosenthal E.
Raising concerns around the use of armed security guards in health care settings, this newspaper article and companion podcast report on the experience of a patient who disclosed a need for mental health treatment upon arriving at a hospital where staff failed to appropriately address his psychiatric condition and instead treated his physical injuries. The patient became increasingly agitated and hospital security personnel ultimately used weapons to subdue him.
Lundberg GD.
Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a patient safety problem, this commentary outlines recommendations from the recent Improving Diagnosis in Healthcare report and calls for the creation of diagnostic management teams to enhance care quality.
Daley J. Colorado Public Radio. February 17, 2015.
Patient and family stories of harm are increasingly promoted as a strategy to provide insights into medical errors. This radio segment interviews a patient advocate whose daughter died due to medical errors, including failure-to-rescue and a health care–associated infection, and who speaks about that experience to educate clinicians on the importance of patient safety and listening to patients' families.
Stock S; Putnam J; Carroll J; Pham S.
Hospital reporting of errors in the United States has been suboptimal. This news video investigates the effectiveness of a state reporting initiative in California. Although hospitals have reported 6282 adverse events to the state in 4 years, patient safety experts suggest that those results do not reliably represent all the incidents that should have been submitted.