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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 - 20 of 35 Results
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.

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.

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.

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.

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.

Clark C. MedPage Today. September 14, 2021. 

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.

Patient Safety Movement. September 17, 2021. 

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.  

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

Caceres V. US News World ReportMarch 1, 2021.

Patients and families have an important role in reducing potential for error and harm. This article highlights a set of tactics for patients to enhance the safety of their care that include preparing for doctor’s appointments, asking questions and seeking second opinions.

Zeynep Tufekci. The Atlantic. February 26, 2021

Failures in communication have impacts on patients, teams, organizations and society. This article discusses five weaknesses in pandemic messaging that were counterproductive including use of shaming instead of empathy to engage the public, lack of detail on suggested strategies and insufficient advice to support public adoption of harm reduction activities.

Boodman SG. Washington Post. February 20, 2021.

Difficult diagnostic journeys are compounded by lack of clinician empathy, bias awareness, and critical thinking. This piece shares the story of a patient whose efforts to identify the cause of her pain were hampered by heuristics, premature closure, and poor patient relationship building.

Yong E. The Atlantic. November 13, 2020.

Stressful working conditions are known to increase the potential for medical mistakes. This article shares the perspectives of acute care staff about the emotional and physical toll they've experienced as a result of the COVID-19 pandemic.

Heath S. Patient Engagement HIT. October 29, 2020.

Twitter is evolving as a useful data source for patient safety. This news story discusses an examination of public use of a patient-complaint hashtag that recorded patient experiences of misdiagnosis, disrespect and miscommunication that contributed to poor relations with physicians, medical errors, and harm.
Czeisler MÉ, Marynak K, Clarke KEN, et al. MMWR Morb Mortal Wkly Rep. 2020;69:1250-1257.
This nationwide survey of U.S. adults found that many respondents (40.9%) have avoided routine, urgent and emergent medical care during the COVID-19 pandemic. Avoidance of urgent or emergency care was significantly higher among unpaid caregivers for adults; persons with underlying medical conditions; persons with health insurance; non-Hispanic Black, Hispanic, or Latino adults; young adults; and persons with disabilities.