U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Patient Safety Network

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.

Search All Content

Advanced Search
Search Tips
Save
Download citations
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Commonly Searched Resource Types
Additional Filters
All Resource Types
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor
Displaying 1 - 12 of 12 Results
  • 20
  • 50
  • 100
    • When medical error becomes personal, activism becomes painful.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • 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.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • 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.
    The Uneven Burden of Maternal Mortality in the U.S.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

    Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
    Examining the Status of VA’s Electronic Health Record Modernization Program.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

    Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.
    At US hospitals, a drug mix-up is just a few keystrokes away.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Kelman B. Kaiser Health News. April 29, 2022.

    Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.
    Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Washington, DC: VA Office of Inspector General; March 17, 2022.

    Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.
    Curated Libraries
    Maternal Safety
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • 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.
    Artificial intelligence makes bad medicine even worse.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Aschwanden C. Wired Magazine. January 10, 2020.
    The unintended consequences of artificial intelligence (AI) in healthcare continue to generate clinician concern. This magazine piece examines the potential diagnostic improvements to be realized from AI while cautioning about its premature use generating overdiagnosis and overtreatment.
    Electronic Health Record (EHR) Safety and Usability: See What We Mean.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • MedStar Health National Center for Human Factors in Healthcare.
    Electronic health records (EHR) optimize information functions in care environments while paradoxically introducing inefficiencies and opportunities for error due to usability problems. This series of videos draws from usability research to illustrate how ineffective EHR design can reduce the safety and reliability of care processes that rely on these systems.
    Back To Top
    Terms and Conditions | Privacy Policy | External Link Disclaimer

    Connect With Us

    Facebook Twitter You Tube LinkedIn

    Sign up for Email Updates

    Agency for Healthcare Research and Quality

    5600 Fishers Lane
    Rockville, MD 20857
    Telephone: (301) 427-1364