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 51 Results

Global Knowledge Sharing Platform for Patient Safety.

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World Health Organization.

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.

Annual Speak Up Data Reports.

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Stratford, London; The National Guardian.

Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

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Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

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American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2023;71(7):2052-2081.

Inadvertent overprescribing and polypharmacy in the 65-year old or older patient population is a contributor to patient harm. The Beers criteria serve as standard guidance for clinicians to prevent the potential for Inappropriate medication prescribing. This guideline updates existing recommendations and simplified the listing by removing rarely used medications in the geriatric population.

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).

Guidelines on Human Factors in Critical Situations 2023.

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Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.

Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.

Challenge Competition: Impact of Patient Safety Tools.

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

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

Serious Reportable Events in Massachusetts.

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Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety.

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Jewell ML, Jewell HL, Singer R, et al. Aesthetic Plast Surg. 2023;47:1234-1238.

Fentanyl is a high-risk medication, whether prescribed by a health professional or obtained illicitly. This patient safety advisory encourages healthcare providers to educate their patients on the risks of counterfeit fentanyl.

Curated Libraries

Value and Patient Safety

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.

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

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Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders.

ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

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Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.

Medication errors associated with surgery and other invasive procedures can result in patient harm. This 10-element guidance suggests effective practices to address identified weaknesses in perioperative and procedural medication processes. Recommendations provided cover topics such as drug labeling, communication, and risk management.

AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI: Final Report.

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Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019.

Central line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are a persistent challenge for health care safety. This report shares the results of a 6-cohort initiative to reduce CLABSI and/or CAUTI infection rates in adult critical care. Recommendations for collaborative implementation success are included.

APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.

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The APSF Committee on Technology. APSF Newsletter. 2022;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.

Toolkit for Preventing CLABSI and CAUTI in ICUs.

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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

Curated Libraries

Medication/Drug Errors

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...

Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

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