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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 - 7 of 7 Results
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    • Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.
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    • National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

    Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.
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    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.
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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.
    Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
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    • Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.
    Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
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    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.
    High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.
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    • Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
    Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
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