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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 21 Results

Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.

Racist behavior directed at either patients or clinicians can degrade the safety of care. This report reviewed over 500 race- or ethnicity-related patient safety incidents to determine the types of actions involved and the role of the individual committing the action. In addition, the impact of the behaviors on the mental health of providers is examined. The report suggests strategies for understanding, detecting, and reducing health disparities.

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.

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.

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.

Andreou A. Scientific AmericanMay 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Garb HN. Psyche. March 22, 2022.

A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of implicit biases, test inaccuracy, and data weaknesses in diagnosis of mental health conditions in both children and adults. The author provides recommendations for clinicians and researchers to reduce the impact of bias on diagnosis.

Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. 

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop reviewed the evidence base examining challenges in cancer diagnosis, discussed suggestions for improvement in the field, and looked toward a safer future for cancer patients.

Patient Safety Movement. September 17, 2021. 

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.  

Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.   
Czeisler MÉ, Marynak K, Clarke KEN, et al. MMWR Morb Mortal Wkly Rep. 2020;69:1250-1257.
This nationwide survey of U.S. adults found that many respondents (40.9%) have avoided routine, urgent and emergent medical care during the COVID-19 pandemic. Avoidance of urgent or emergency care was significantly higher among unpaid caregivers for adults; persons with underlying medical conditions; persons with health insurance; non-Hispanic Black, Hispanic, or Latino adults; young adults; and persons with disabilities.

Hoffman J. New York Times. May 16, 2020.

Health care worker stress is a known contributor to disruptive behavior, error and clinician suicide.  This story discusses the impact of the COVID-19 pandemic on psychological strain in clinicians and highlights peer support and other techniques to mitigate its negative effects.
Guirguis A. The Pharmaceutical Journal. 2020;304.
Users of illicit substances are vulnerable to a variety of health concerns. This article discusses how the COVID-19 pandemic places illicit drug users at increased risk for COVID-19 due to their predisposition to infection and social contact; how disruptions to illicit drug supply chains increase risk for overdose due to drug substitution and; the impact of missing out on drug treatment services. The piece highlights the role of pharmacists in keeping this marginalized patient population safe.

Jee C. MIT Technology Review. April 22, 2020.

Patient safety can be challenged even after patients are discharged and return home. This story discusses the potential for psychological trauma in patients who survive a COVID-19 ICU stay. Strategies discussed to address the problem include medication, cognitive therapies and personal wellness instruction. 

Galewitz P.  Kaiser Health News. March 25, 2020.

Home care is a common option for older and disabled patients for managing their chronic conditions. This story highlights provider concerns associated with provision of care at home during the COVID-19 pandemic.