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.

Displaying 1 - 9 of 9 Results

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

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Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.

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.

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

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.

‘You’re going to release him when he was hurting himself?’

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Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

How the pandemic defeated America.

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Yong E. The Atlantic. September 2020

This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.

Broken, fragmented health-care system failed daughter who died by suicide.

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Klowak M. CBC News. March 9, 2020.

System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.

The glaring loophole in U.S. virus response: human error.

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Ehley B. The glaring loophole in U.S. virus response: human error. Politico. March 2, 2020.

This news story illustrates the potential for failure - attributable to human error, inexperience or external stressors - in response to a large-scale emerging threat to public health.

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