The PSNet Collection

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.

Addressing Workplace Violence and Creating a Safer Workplace

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Perspective on Safety October 31, 2023

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

AI in medicine needs to be carefully deployed to counter bias – and not entrench it.

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Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023.

Systemic biases are present in data tools, training and culture across health care. This article discusses weaknesses in artificial intelligence algorithms that are poised to further entrench biases and inequities into health care systems. The authors highlight the role of regulators and industry in combating the presence of biases in decision making technologies.

Towards safe conversational agents in healthcare.

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Denecke K. Stud Health Technol Inform. 2023;302:157-161.

The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

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Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

AI may be on its way to your doctor’s office, but it’s not ready to see patients.

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Tahir D. KFF Health News. May 12, 2023.

Real-time use of artificial intelligence (AI) in health care settings continues to cause concern despite its potential to improve care. This article examines current efforts to develop AI applications for health care and the reasons for oversight to protect privacy, reduce bias, and prevent misinformation.

How the opioid backlash went wrong.

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Freedman DH. Newsweek Magazine. May 12, 2023.

The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This article discusses precursors to the system failure affecting these patients and treatment options that work given access and supply constraints.

Listening, Learning, Responding to Concerns.

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Newcastle Upon Tyne, UK: Care Quality Commission; March 2023.

The ability to raise patient safety concerns without fear of retribution is a core element of a safety culture. This pair of reports examines a failure in organizational response to an employee expressing concerns. The first report examines an explicit whistleblowing incident in the National Health Service that was poorly managed. The second looks at broader system-level elements needed to support effective responses when concerns are voiced.

Mothers face broken addiction treatment system.

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D'Ambrosio A. MedPage Today. March 31, 2023.

Maternal health is challenged across social strata but notably amongst populations of color, economic disparity, and social minority. This article discusses barriers mothers face trying to manage substance use disorders during pregnancy and after birth due to system problems and stigma.

What's changed 1 year after RaDonda Vaught's conviction?

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Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.

The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems response to errors and the clinicians who make them. This news article examines how health care organizations renewed efforts to establish and nurture a culture of safety and error reporting in service of safe patient care and learning from mistakes.

Maternal Safety and Perinatal Mental Health

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Perspective on Safety March 29, 2023

This piece focuses on perinatal mental health and efforts to improve maternal safety.

In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health

Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

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Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.

Pediatric mental health is a patient safety concern. This news story outlines the challenges to available services to address this need, tactics to keep young patients from harming themselves or others, and system-level approaches to improvement.

Do no unconscious harm.

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Ortega RP. Science. 2023;379:870-873.

Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and patient/physician communication. This article highlights efforts to understand implicit biases in health care professionals. It discusses initiatives and tools in development to reduce the presence of unconscious bias in health care.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

NHS staff cried in safety interviews, says watchdog.

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Reed J. BBC. February 27, 2023.

Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing investigation in the British National Health Service to examine factors in ambulance services that minimize its safety and effectiveness. Clinicians interviewed revealed serious problems with the work cultures.

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

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Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.

Gaps in care for psychologically vulnerable patients can result in harm to family members and self-harm. This report examines organizational failures in responding to staff and clinical leaders’ concerns regarding access, triage, and care continuity for mental health patients. Recommendations for improvement include same-day access to appropriate specialty care, medication management, and risk documentation.

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

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Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.

'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols?

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Renault M. STAT. February 6, 2023.

Emergent care situations are vulnerable to a range of factors that reduce care safety and access. This article examines safety culture, implicit biases, and system issues that impacted access to needed emergency care for a patient involved in a police action.

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