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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 - 13 of 13 Results

Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

Gebeloff R, Thomas K, Silver-Greenberg J. New York TimesDecember 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.

Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

Yong E. The Atlantic. September 2020

This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.
Dolan J, Mejia B. Los Angeles Times. 2020;July 24.
Worker safety has ramifications for patient care in both routine and crisis situations. This story highlights a testing gap that has the potential to degrade efforts to minimize the spread of COVID-19 in nursing homes: the lack of coronavirus testing of inspectors visiting the facilities to assess infection prevention readiness.  
Khazan O. The Atlantic. 2020;July 6.
Residential care facilities have been particularly challenged by COVID-19. This article outlines how lack of access to protective equipment, staff training, accurate statistics and effective employee testing have hindered the ability of nursing homes to protect patients and staff from the virus.    

Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.

National Academy of Medicine. April-June 2020.

Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. This webinar series covered topics such as keeping nursing home residents and the staff that care for them safe, practice integration in skilled nursing facilities, communication and collaboration in times of crisis, testing and SARS-CoV-2 transmission prevention tactics.

Ellis B, Hicken M. CNN. May 14, 2020.

Long-term care and skilled nursing facilities care for a patient population particularly vulnerable to COVID-19 infection. This article discusses an analysis of a large nursing home system and gaps in its workforce safety program. Problems highlighted included communication practices that fall short of what is needed to assure staff safety as they care for nursing home residents.

Shaprio J. National Public Radio. April 15, 2020.

Access to care has been strained by the COVID-19 pandemic. This radio segment discusses how implicit biases can affect care of patients with disabilities. It highlights how preconceptions about this patient population could limit their access to treatments should they become ill.