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 - 18 of 18 Results

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.

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.

The Uneven Burden of Maternal Mortality in the U.S.

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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.

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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.

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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.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

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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

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.

The pain was unbearable. So why did doctors turn her away?

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Szalavitz M. Wired Magazine. August 11, 2021.

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Machine learning is booming in medicine. It’s also facing a credibility crisis.

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Ross C. STAT. June 2, 2021.

Artificial intelligence and machine learning are often promoted as tools with impressive potential for generating rapid improvements in healthcare decision making. This news story highlights how underlying problems and testing failures limit the trustworthiness of conclusions drawn by the systems.

Black or 'other'? Doctors may be relying on race to make decisions about your health.

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Smith J, Spodak C. CNN. April 25, 2021.

Race-adjusted decision making tools perpetuate the potential for diagnostic error and care delay. This article examines race correction as a form of bias in health care and discusses efforts to reduce the use of race-adjusted algorithms.

When health care moves online, many patients are left behind.

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Renault M. Wired Online. 2020.

The emergence of telemedicine as a primary mode of health care delivery in response to the COVID-19 pandemic is seen as a tool to improve safety and access, yet gaps in access to the requisite technologies exist. This article examines how technological limitations present safety issues to patients, such as unreliable access to personal computers, cell phones and robust internet connections.

With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications.

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Brodwin E. Stat News. April 14, 2020.

Patients with cancer and other chronic disorder treatment needs have been negatively affected by the restructuring of services to reduce the spread of the coronavirus. This story discusses company strategies to prepare to virtually support patients with a range of conditions. The author shares communication and support tactics to keep patients safe until they can get their appointments.

Artificial intelligence makes bad medicine even worse.

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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.

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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.

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