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Patient Safety Network

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 - 9 of 9 Results
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    • Improving Diagnostic Safety and Quality
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    • Perspective on Safety April 26, 2023

    Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

    Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

    Curated Libraries
    Value and Patient Safety
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    • 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.
    Misdiagnosis in the emergency department: time for a system solution.
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    • Edlow JA, Pronovost PJ. JAMA. 2023;329:631-632.
    Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.
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    Diagnostic Safety
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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.
    Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.
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    • Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.
    The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
    The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science.
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    • Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

    Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.
    Curated Libraries
    Maternal Safety
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    • 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, collaborative initiatives, teamwork, and trigger tools.
    Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.
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    • Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.
    This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.  
    On the Other Hand
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    • WebM&M Case May 1, 2007
    A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
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