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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 85 Results

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.
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, care standardization,teamwork, unit-based safety initiatives, and...

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.
Waldman A, Kaplan J. ProPublica. 2020.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.
Hafner K. New York Times. 2020;May 25.
The uncertainties surrounding coronavirus transmission and treatment are causing patients with known conditions to forgo needed medical care. This article outlines how COVID-19 fear and anxiety are primary contributing factors in patient decisions to delay transplants and other necessary treatments.

Alesse L, Dukakis A, Tatum S, Mosk M. ABC News. March 20, 2020.

Delays in elective surgery and other procedures have the potential to lessen safe patient care. This news story describes the decision-making dilemma for physicians to limit patient access to care during the COVID-19 pandemic. Their concern is that the delays have the potential to result in diagnostic and treatment service deviations that could result in harm.

Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.

Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade patient safety. This news story highlights the findings of a government report highlighting overcrowding and production pressures as factors resulting in the death of a patient waiting for care who initially presented at the ER with symptoms of heart attack.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Cierniak KH; Gaunt MJ; Grissinger M.
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Ready T. HealthLeaders Media. September 26, 2017.
Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enhancing safety of transitions and facilitating design of sustainable improvements. The article also highlights successful interventions that have benefited from leadership engagement, such as the I-PASS program.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.
Clements K. Nursing Management (Springhouse). 2017;48.
High reliability has yet to be achieved in health care organizations. This magazine article described how a 13-hospital health system used handoff standardization tools such as I-PASS to enhance the reliability of patient transitions.