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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 33 Results
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2022;Epub Dec 5.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
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 APSF Committee on Technology. APSF Newsletter2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.
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...
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, collaborative initiatives, teamwork, and trigger tools.
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156:76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.

The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, American Association of Critical‐Care Nurses, and American College of Chest Physicians. March 26, 2020.

Innovations must be incorporated into care processes with safety in mind. This announcement shares insights to mitigate strategies that may cause patient harm through alternative use of ventilators to support multiple patients with compromised respiratory function.
Bickham P, Golembiewski J, Meyer T, et al. Am J Health Syst Pharm. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatrics. 2018;142.
This revised set of guidelines suggests standards to ensure high-quality care for pediatric patients in the emergency department, including a section on improving patient safety. Key recommendations focus on pediatric emergency care coordinators and implementing quality control mechanisms.
Gelb AW, Morriss WW, Johnson W, et al. Anesth Analg. 2018;126:2047-2055.
Safe anesthesia is a global concern. These standards provide guidance and recommendations for clinicians, administrators, and governments as they review, implement, and manage anesthesia services in a variety of care environments. The standards center on themes related to professional qualification; facilities and equipment; medications and intravenous fluids; monitoring; and anesthesia delivery.
Obstet Gynecol. 2016;128:e54-60.
Incidents involving maternal harm require analysis to provide learning and assist design of prevention strategies. This consensus document outlines an organizational process to determine cases for review and provides a set of diagnostic and complication screening criteria to assess severe maternal morbidity incidents for quality review. The document supersedes the Sentinel Event Alert on maternal harm.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.
London, UK: Royal College of Surgeons of England; 2016.
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.