The PSNet Collection

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.

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. The comments submission period is now closed.

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.

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.

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

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Muoio D. Fierce Healthcare. April 21, 2023.

Notable problems have occurred during the testing of the new electronic health records (EHR) system being designed for use in Veterans Affairs hospitals. This news article discusses the temporary halt of the project as the Department reassesses issues that have arisen during test rollouts in several United States hospitals.

Preventing home medication errors.

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Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.

Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.

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Donovan-Smith O. Spokesman Review. March 15, 2023.

Implementations of electronic health record (EHR) systems are complex efforts that have the potential for injury, should failure occur. This article discusses the Veterans Affairs EHR implementation project that is associated with six incidents of patient harm and calls for improvement at the federal level.

Why hospitals still make serious medical errors—and how they are trying to reduce them.

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Landro L. Wall Street Journal. March 12, 2023.

Patient harm from health care is persistent despite decades of effort to address problems that degrade care. This article discusses the potential that improved technology use has in reducing medication errors, falls, surgical errors, and high-risk hospital-acquired infections.

Hospital ‘black boxes’ put surgical practices under the microscope.

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Sadick B. Wall Street Journal. March 19, 2023.

Safety information systems that track action in real time can reveal a trove of data about how teams and procedures progress. This news article describes the use of a black-box system in the operating room. Its use by hospitals in the United States is described to illustrate the value of black box data to inform learning and improvement strategies.

I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.

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Tamayo-Sarver J. Fast Company. March 13, 2023.

Artificial intelligence (AI) harbors risks and biases that can misinform clinicians, researchers, and patients. This article discusses experience with an AI application in the emergency setting and the diagnostic mistakes it made. The author offers caution when proceeding with the use of AI as a diagnostic tool.

Using A.I. to detect breast cancer that doctors miss.

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Satariano A, Metz C. New York Times. March 5, 2023.

Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and timeliness improvement. This article discusses a successful AI breast cancer screening program in Hungary and its potential to illuminate efforts to spread AI-enhanced diagnosis as a tool for physician decision making.

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.

Better off at home--how we fail children with complex medical conditions.

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Newcomer CA. N Engl J Med. 2023;388:198-200.

Children with complex care needs present unique challenges for both parents and clinical teams. This commentary offers a physician-parent’s perspective on weaknesses in the care system that decreased medication safety for her child and also decreased patient-centeredness, including lack of a respect for the family as care team members.

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.

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.

Press Play on Safety Conversations.

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Healthcare Excellence Canada. 2022.

After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive communication should a failure or near-miss occur. There are two distinct sections of materials: one for established healthcare professionals, and another for patients, students, and caregivers.

Her child was stillborn at 39 weeks. She blames a system that doesn’t always listen to mothers.

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Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

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.

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