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 130 Results

A deadly epidural, delivered by a doctor with a history of mistakes.

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Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

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Westwood R. Kaiser Health News. January 12, 2023.

Lack of access to obstetric care impedes safe treatment for mothers. This story describes challenges one mother experienced in finding care during a miscarriage due to abortion policies and the steps she and her family took to manage her condition.

ER doctors misdiagnose patients with unusual symptoms.

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Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

During in-flight emergencies, sometimes airlines’ medical kits fall short.

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Ramachandran V. Kaiser Health News. January 6, 2023.

Inadequate equipment and personnel training degrade the reliability of individuals to provide safe care in an emergency. This article discusses inconsistent preparedness throughout commercial aviation to support care during an in-flight medical situation; it suggests federal oversight of medical kits may help to ensure their completeness and improve the potential for safety should care be required.

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

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Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments is January 26, 2023.

From heart disease to IUDs: how doctors dismiss women’s pain.

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Bever L. Washington Post. December 13, 2022.

Gender and racial bias contributes to inadequate and delayed care. This story focuses on women who have experienced harm due to their pain concerns being marginalized or dismissed.

National Patient Safety Board Act of 2022.

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HR 9377, 117th Cong, 2d Sess (2022).

The need for a national government-led patient safety effort has long been advocated for. This legislation outlines the structure of a federal agency to provide support for patient safety data collection, national incident analysis, and recommendation development.

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

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Washington DC; Office of Senator Mark Warner: November 25, 2022.

There is lack of consensus concerning the need for increased system and policy attention on cybersecurity challenges as a threat to patient safety. The report suggests modifications within the federal government infrastructure to increase attention to cybersecurity as a safety issue, public/private partnership opportunities, and policy development to reduce the potential for cyberattacks that impact care delivery.

Walgreens will stop judging its pharmacy staffers by how fast they work.

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Kaplan A. NBC News. October 27, 2022.

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.

Medicare fines for high hospital readmissions drop, but nearly 2,300 facilities are still penalized.

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Rau J. Kaiser Health News. November 1, 2022.

The COVID-19 pandemic necessitated adjustments in activities across health care to address patient care and staffing demands. This news article discusses COVID-19’s impact on the hospital-acquired condition reduction program, and how 43 percent of US hospitals failed to reach readmission goals.

The National Healthcare System Action Alliance to Advance Patient Safety.

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US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.

‘They can’t ignore us any more’: five women on long Covid and medical misogyny.

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Lu D. The Guardian. October 18, 2022.

Disrespect for women around the world is known to occur in health care that contributes to diagnostic delay and lack of trust in the system. This news article describes challenges met by 5 women patients seeking diagnosis and treatment for long COVID.

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

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Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232.

Care coordination failures reduce the effectiveness of communication, information transfer, and patient monitoring to the determent of safety. This report examines the current state of interfacility transfers in 45 veteran facilities to find that, while process requirements were basically met, improvements could be made to medication list transfer, nursing communication, and general service evaluation.

People of color with long COVID face uphill battle to be heard.

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Farah T. Scientific American. September 22, 2022.

Gaslighting women and patients of color is known to occur in health care for both common and emerging conditions. This news article describes challenges met by a patient seeking diagnosis and treatment for long COVID.

Embedded bias: how medical records sow discrimination.

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Tahir D. Kaiser Health News. September 26, 2022.

Negative patient representations in medical records perpetuate stereotypes that can affect care over time. This story discusses how written notes using stigmatizing language reflect bias and physician disrespect that serve as clues to misdiagnosis. Black patients and those patients named as "difficult" were particularly vulnerable to damaging representation in notes.

When medical error becomes personal, activism becomes painful.

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Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.

Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them.

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Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

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Farnborough, UK: Healthcare Safety Investigation Branch; 2022. HSIB Report no. NI-005831

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.

'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death.

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Mills M. The Guardian. September 3, 2022

Families experiencing medical error can harbor frustration with the system but also with themselves for allowing care mistakes to take their loved one. This first-person account shares the story of a mother’s loss of a daughter to sepsis. The memoir illustrates how lack of respect for a family’s concern contributed to the incident.

How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners.

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Jefs L, Kuluski K, MacLaurin A, et al. Ottawa, Ontario, Canada: Healthcare Excellence Canada; 2022.

Patient engagement in safety improvement goes beyond activities related to direct care. This report highlights the value that patient perspectives bring to the effort to translate the results of a national measures program to strengthen strategic progress and patient and family program involvement.

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