Skip to main content

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

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 102 Results
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.

The global effect of harm associated with preventable drug errors is substantial. This report discusses the human and financial impact of medication errors in a variety of countries, prescribing process improvement, established efforts to enhance medicine use safety, and avenues for national medication safety achievement.

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.

Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021. 

The emergence of telemedicine during the COVID-19 pandemic has situated it to become an accepted model for health service provision despite safety concerns. This white paper discusses a 6-item framework to enhance the safety, equity, and person-centeredness of telemedicine and recommendations for embedding safer methods into telemedicine practice.
Horsham, PA: Institute for Safe Medication Practices; 2022.
This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.
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, care standardization,teamwork, unit-based safety initiatives, and...

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.  

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National Academies Press.

Primary care is the starting point for safe, equitable health care. This report outlines a system-focused implementation framework to enhance person-centered, accessible primary care. The approach aims to a focus on generating accountability through payment reform, multi-disciplinary team development, workforce support, and digital health utilization.

Evanston, IL: Society to Improve Diagnosis in Medicine; March 2021.

Telehealth is commonly used to deliver health care, yet its safety across the continuum has yet to be determined. This report highlights perspectives on the potential of telediagnosis and examines its reach, effectiveness, adoption, implementation, and maintenance, to inform actions to ensure its safe use.

Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.

Telehealth is becoming a standard care mechanism due to COVID-19 concerns. This special issue brief discusses telediagnosis, shares system and associate factors affecting its reliability, challenges in adopting this mode of practice, and areas of research needed to fully understand its impact. This issue brief is part of a series on diagnostic safety.

Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.

Tracking problems with health information technology (Health IT) is an important strategy to drive improvement. This report outlines general health IT and decision support actions to inform action, and discusses the role that regulation and accreditation have for driving improvement.

Washington DC: National Quality Forum; 2020.

This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach to improve the US health care system. Five strategic objectives are provided--one of which focuses on safe care. The report outlines a stratum of actions on which to anchor work over the next decade to generate improvements and increase value. The authors recommend activities that enhance areas of focus such as information technology, equity and patient engagement.

Ofri D. Boston, MA: Beacon Press; 2020. ISBN 9780807037881.

Human and system failures combine to result in preventable patient harm. This book highlights the need for frontline error mitigation tactics such as checklists and electronic health record improvements to be implemented in conjunction with comprehensive system reforms to result in lasting change.

Philadelphia, PA: Pew Charitable Trusts; March 2020.

Electronic health records both enhance and challenge the safety of care processes. This report examines the potential of a government initiative to track EHR problems to inform system development, purchase decisions and implementation strategies. It describes an initiative to embed usability elements that support safe and effective system use to reduce patient harm. 

Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.

Maternal care safety is challenged by operational, public health and individual provider limitations. The report outlines specific areas of concern for rural hospitals and suggests avenues for improvement. Strategies suggested using simulation to prepare staff and training on implicit bias.
Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
Health information technology (HIT) can improve record keeping, test ordering and prescription legibility. This report highlights its value in assuring diagnostic communications are reliably completed and shares recommendations to support this work. The publication is accompanied by a guide for organizations to act on the recommendations for closed-loop communication.
Lightner NJ, Kalra J, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030204501.
Human-centered processes, technology, and equipment design affect the safety of care. This book provides conference proceedings that explore the application of human factors and ergonomics expertise in six areas of health care (patient safety, health information systems, worker safety, clinician decision support, medical device development, and care of older patients) to improve safety.