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 - 17 of 17 Results

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

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Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative.

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Hado E, Friss Feinberg L. J Aging Soc Policy. 2020;32:410-415.

These authors discuss the role of family caregivers during the COVID-19 pandemic and suggest avenues to support the relationship between families and residents of long-term care facilities, including strengthening communicating channels, activating family councils, and utilizing gerontological social work students.

Patient Safety.

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Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.

The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.

Lessons learned from a death outside a hospital's doorstep.

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Palmer J. Patient Saf Qual Healthc. May/June 2019.

Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

Making infection prevention and control everyone's business? Hospital staff views on patient involvement.

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Sutton E, Brewster L, Tarrant C. Health Expect. 2019;22:650-656.

Interviews with frontline hospital staff and executive leaders revealed that they were generally supportive of engaging families and patients to promote infection prevention in the clinical setting when using a collaborative approach. Staff identified certain challenges including concerns related to the extent of responsibility patients and families should bear with regard to infection prevention as well as risks to infection control posed by patients themselves.

Still Failing the Frail.

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Simmons-Ritchie D. Penn Live. November 15, 2018.

Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.

Losing Laura.

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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.

Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.

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Vonnes C, Wolf D. BMJ Open Qual. 2017;6:e000038.

Falls are a persistent problem for hospitalized oncology patients, despite protocols to help prevent them. This improvement project tested strategies to engage care teams in fall prevention, including educating patients and families about the risk of falls to help reduce these sentinel events.

Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.

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Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.

Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.

For Colorado mom, story of daughter's hospital death is key to others' safety.

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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.

Medical errors leave devastating impact on families, professionals.

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Bernhard B.

This newspaper article relates how medical mistakes affect both patients and clinicians and offers tips for patients and families to prepare for surgery.

Hospital safety: your responsibility or theirs?

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Teegardin C. Atlanta Journal-Constitution. April 28, 2013.

This newspaper article reports on the role of patients and families in preventing health care–associated infections.

Implementation of Condition Help: family teaching and evaluation of family understanding.

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Hueckel RM, Mericle JM, Frush K, et al. J Nurs Care Qual. 2012;27:176-81.

Some hospitals have begun allowing patients and families to directly summon a rapid response team. This implementation study reports on the training process for establishing a family-activated rapid response team at a children's hospital.

Family alert: implementing direct family activation of a pediatric rapid response team.

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Ray EM, Smith R, Massie S, et al. Jt Comm J Qual Patient Saf. 2009;35:575-580.

This study reports on a pediatric hospital's experience with allowing family members to activate the rapid response team.

Ways You Can Help Your Family Prevent Medical Errors!

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Agency for Healthcare Research and Quality; AHRQ.

A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.

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