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.

Displaying 1 - 12 of 12 Results

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Nursing and Patient Safety

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Patient Safety Primer April 21, 2021

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.

Missed or Rationed Nursing Care.

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J Nurs Manag. 2020;28(8): i-iv, 1767-2275.

Incomplete nursing care is known to affect care quality and safety. This special issue documents the global problem of missed or rationed nursing care in a variety of settings and countries. Articles featured in this special issue examine systemic issues, explore interventions, and evaluate measurement tools.

Hidden in plain sight — reconsidering the use of race correction in clinical algorithms.

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Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882.

Physicians commonly use diagnostic algorithms and practice guidelines to individualize risk assessment and guide clinical decisions. The authors discuss the possible dangers of using race-adjusted algorithms due to their potential to lead to diagnostic errors and delays in care.

Patient Safety 101

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Patient Safety Primer September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

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Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.

Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.

Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs.

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Darrah NJ, O'Connor NR. J Pain Symptom Manage. 2016;51:959-962.e2.

Hospice providers often lack access to patient records, which can hinder patient transitions in this setting. This project report outlines an effort to develop curriculum associated with hospital-to-hospice handoffs to enhance transition practices and communication needs unique to palliative care.

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

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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.

Improving Communication During Transitions of Care.

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Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404097.

This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.

Clinical Handover: Critical Communications.

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Med J Aust. 2009;190(s11):s108-s157.

This supplement discusses Australian efforts to improve handover safety with emphasis on flexible standardization, communication improvement, and information sharing tactics.

Care transitions and home health care.

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Boling PA. Clin Geriatr Med. 2009;25:135-48, viii.

This article reviews the literature on transitions of care, discusses interventions, and suggests that transitional care processes supported by effective home care programs can reduce rehospitalization.

The effect of medication reconciliation in elderly patients at hospital discharge.

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Midlöv P, Bahrani L, Seyfali M, et al. Int J Clin Pharm. 2012;34:113-9.

Medication reconciliation by clinical pharmacists was associated with improvement in the incidence of medication errors at hospital discharge.

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