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 247 Results

Addressing Workplace Violence and Creating a Safer Workplace

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Perspective on Safety October 31, 2023

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

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Allen A. KFF Health News. June 21, 2023.

A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.

Death of a patient by suicide is a sentinel event. This report examined one incident and identified care deficiencies associated with lack of mental health referrals and pain management follow-up. In addition, post-event process gaps occurred, impacting learning and resolution such as a delay in the inquiry launch, peer review, and clinical review of the incident. Claims that the facility purposely sought to hide information that the suicide happened were unsubstantiated.

Inside the preventable deaths that happened within a prominent transplant center.

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Blau M. ProPublica. June 14, 2023.

Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.

AI in medicine needs to be carefully deployed to counter bias – and not entrench it.

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Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023.

Systemic biases are present in data tools, training and culture across health care. This article discusses weaknesses in artificial intelligence algorithms that are poised to further entrench biases and inequities into health care systems. The authors highlight the role of regulators and industry in combating the presence of biases in decision making technologies.

Government Response to the Investigation into the Death of Elizabeth Dixon.

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Department of Health and Social Care. London, England: Crown Copyright; 2023

Following an investigation into the death of 11-month-old Elizabeth Dixon in the UK’s National Health System (NHS), a report with 12 recommendations for system improvement was released. This report sets out the government’s response to each recommendation, including the agency responsible for each recommendation, where applicable.

Towards safe conversational agents in healthcare.

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Denecke K. Stud Health Technol Inform. 2023;302:157-161.

The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

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Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.

As cancer drug shortages grow, some doctors are forced to ration doses or delay care.

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Kopf M, Beck C. NBC News. May 26, 2023.

Lack of access to appropriate cancer medications can be particularly difficult for patients and clinicians. This news article discusses the current shortage of chemotherapy drugs, the psychological and physical harm potential in the situation and what should be done to improve medication supply.

People for Patient Safety.

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PULSE Center for Patient Safety Education & Advocacy. Second Monday of every month; 7:00 PM (eastern).

Patient advocates and caregivers play a valuable role in keeping patients safe. This reoccurring session provides a communication forum for individuals to discuss topics and shared experiences as they support patient safety. The next monthly session will be held June 12, 2023.

A national safety board made transportation safer and could do the same for health care, advocates say.

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Jaklevic MC. CNN. May 30, 2023.

Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.

Voices from the Frontlines of Health Care Safety.

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Boston, MA; Betsy Lehman Center for Patient Safety; April 2023.

Well-told stories can motivate change. This video translates the experience of Massachusetts patients and family members with medical error for a broad audience. Clinicians also participate and share perspectives on problems in care systems that contribute to patient harm.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

AI may be on its way to your doctor’s office, but it’s not ready to see patients.

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Tahir D. KFF Health News. May 12, 2023.

Real-time use of artificial intelligence (AI) in health care settings continues to cause concern despite its potential to improve care. This article examines current efforts to develop AI applications for health care and the reasons for oversight to protect privacy, reduce bias, and prevent misinformation.

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