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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 - 14 of 14 Results
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2023 goals are now available.
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.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Institute for Safe Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2020.

Smart pumps are widely available as a medication safety tool yet there are challenges affecting their reliable use. This guideline expands on earlier recommendations  to support smart pump use in both hospitals and the ambulatory setting. The material provides recommendations that address infrastructure, drug libraries, quality improvement data, workflow and electronic health record interoperability concerns.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Trent M, Dooley DG, Dougé J, et al. Pediatrics. 2019;144:e20191765.
Children and adolescents are particularly vulnerable to systemic weaknesses in health care. This guidance examines the impact of racism and implicit biases on pediatric patients. The policy summarizes the evidence on institutionalized racism and health to motivate the adoption of strategies to reduce that impact at the system and organizational level.
Radiology ES of, Societies EF of R. Insights Imaging. 2019;10:45.
Numerous factors affect safe imaging practice, including potential harms associated with radiation, staffing demands, and patient physical and psychological well-being. This policy statement provides multidisciplinary insights on safety themes in radiology that go beyond the core concern of inappropriate radiation exposure. The authors recommend tactics to reduce the risks related to data protection, service environment, teamwork, burnout, and training.
Women's Health Care Physicians; Committee on Patient Safety and Quality Improvement. Washington, DC: American College of Obstetricians and Gynecologists; 2010. ISBN: 9781934946930.
This manual describes various facets of health care quality and tools for quality improvement in obstetric and gynecologic practice.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.