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 179 Results

Addressing Workplace Violence and Creating a Safer Workplace

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Perspective on Safety October 31, 2023

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

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Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

In Conversation with Kathleen Sanford and Sue Schuelke about Virtual Nursing

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

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.

‘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.

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.

Medication guides: patient medication information. A proposed rule by the Food and Drug Administration.

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May 31, 2023; Fed Register;88:35694-35728.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.

AI in medicine needs to be carefully deployed to counter bias – and not entrench it.

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Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023.

Systemic biases are present in data tools, training and culture across health care. This article discusses weaknesses in artificial intelligence algorithms that are poised to further entrench biases and inequities into health care systems. The authors highlight the role of regulators and industry in combating the presence of biases in decision making technologies.

Towards safe conversational agents in healthcare.

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Denecke K. Stud Health Technol Inform. 2023;302:157-161.

The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

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Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.

A national safety board made transportation safer and could do the same for health care, advocates say.

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Jaklevic MC. CNN. May 30, 2023.

Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

AI may be on its way to your doctor’s office, but it’s not ready to see patients.

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Tahir D. KFF Health News. May 12, 2023.

Real-time use of artificial intelligence (AI) in health care settings continues to cause concern despite its potential to improve care. This article examines current efforts to develop AI applications for health care and the reasons for oversight to protect privacy, reduce bias, and prevent misinformation.

How the opioid backlash went wrong.

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Freedman DH. Newsweek Magazine. May 12, 2023.

The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This article discusses precursors to the system failure affecting these patients and treatment options that work given access and supply constraints.

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

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118th Cong (2023-2024).

Nurse staffing and patient care outcomes are linked, yet variation exists in nursing coverage throughout the United States. This submitted bill aims to legislate a national minimum nurse-to-patient staffing ratio as a strategy to enhance safety and quality improvement.

Laura Levis' death outside ER has changed hospital signage, lighting in Mass.

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Mullins L, Menard F. WBUR. April 27, 2023.

Incomplete information and building design problems can reduce access to care and contribute to harm. This story outlines how the state of Massachusetts responded to the accidental death of a patient unable to get help due to poor signage and incomplete directional information while experiencing an asthma attack.

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