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.
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
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.
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.
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.
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-91.
A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.
Vioque SM, Kim PK, McMaster J, et al. Am J Surg. 2014;208:187-194.
Approximately 1 in 13 deaths of patients with major trauma were considered preventable or potentially preventable in this retrospective review from an urban trauma center. Diagnostic errors during the initial trauma assessment were a frequent contributor to preventable harm.
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