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 1449 Results

Network of Patient Safety Databases Chartbook.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available.

On Patient Safety.

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Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

National Action Alliance to Advance Patient Safety Webinar Series.

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US Department of Health and Human Services. 2023.

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The most recent session explored the successful application of high reliability concepts at the Veterans Health Administration. There have been five videos in this series of offerings from the Alliance supporting its work to improve safety.

Pediatric Diagnostic Safety: State of the Science and Future Directions.

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Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

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Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).

Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors.

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Agency for Healthcare Research and Quality, Rockville, MD. July 2023.

Engaging patients to capture their insights after diagnostic error is one of the top patient safety strategies. This pair of issue briefs describes how organizations can use patient experience to inform improvements in diagnosis. Volume 1: Why Patient Narratives Matter highlights how patient perspectives offer unique information about the impacts of diagnosis-related events on patient care trajectories through the healthcare system. Volume 2: Eliciting Patient Narratives emphasizes that rigorous methods are needed to elicit patient experiences. Both briefs identify areas in which more research is needed about patients’ diagnostic experience.

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

American Hospital Association–McKesson Quest for Quality Prize.

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American Hospital Association.

This award program recognizes organization-wide commitment to five key goals that support high-quality health care: access, health, innovation, affordability, individual as partner. The deadline for submitting an application for the 2024 award cycle has passed.

Leape Ahead Award.

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American Association for Physician Leadership.

Efforts to incorporate respect and patient safety concepts into medical training have been inspired by the work and leadership of Dr. Lucian Leape, founding chairman of the Lucian Leape Institute. This annual award was established to recognize individuals and organizations that focus on developing medical student and resident skills in quality and safety improvement. The 2023 application process is now closed.

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

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Allen A. KFF Health News. June 21, 2023.

A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.

Unequal Treatment Revisited: A Workshop Series.

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Committee on Unequal Treatment, National Academies. 2023.

Health disparities and unequal care contribute to patient and family harm. This 3-component workshop series explored ethnic and racial disparities in health care. A planned September workshop will revisit the findings from the three sessions.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Disclosing medical errors: prioritising the needs of patients and families.

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Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.

Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.

Opportunities for diagnostic improvement among pediatric hospital readmissions.

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Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.

Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.

Inside the preventable deaths that happened within a prominent transplant center.

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Blau M. ProPublica. June 14, 2023.

Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.

The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question.

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Kelen GD, Kaji AH, Schreyer KE, et al. Ann Emerg Med. 2023;82:336-340.

In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

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Choi JJ, Durning SJ. Diagnosis (Berl). 2023;10:89-95.

Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.

After Roe: Challenges in the Provision of Lifesaving Care.

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National Academies of Health.

Delay in access to obstetric care hinders safe treatment for patients experiencing pregnancy complications. This webinar discussed a range of factors affected by abortion restrictions and reviewed options to ensuring safety given legal and other structural impediments. A written brief is forthcoming.

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