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
Narrow Results By
PSNet Original Content
Displaying 1 - 19 of 19 Results

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.

Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

Armstrong D. Allen M. ProPublica. February 18, 2021.

The COVID-19 pandemic has revealed systemic weaknesses in health care access and delivery. This story examines how equipment shortages affected treatment decisions to culminate in rationing of needed therapies and contributed to patient deaths.
Sjoding MW, Dickson RP, Iwashyna TJ, et al. N Engl J Med. 2020;383:2477-2478.
Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.

Wu KJ. New York Times. October 25, 2020.

False-positive test results, while rare, can create conditions for patient harm. This news story discusses negative impacts of a false-positive COVID test. The unintended consequences of the mistake could be unneeded isolation, inappropriate treatment and patient exposure to infection due to isolation strategies in care facilities.  
Waldman A, Kaplan J. ProPublica. 2020.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.
Huetteman E. Kaiser Health News. 2020;August 12.
Health care workers are known to work while unwell due to stigma, commitment, and personal finances. This article discusses presenteeism in the context of the COVID-19 pandemic. It discusses challenges for individuals who feel organizational pressure to return to work despite health concerns for themselves, their families, and their patients.   
Stevis-Gridneff M, Apuzzo M, Pronczuk M. New York Times. 2020;August 8.
Residential care facilities have been challenged by COVID-19. This story examines the weakness of care processes in nursing homes in Europe that have been revealed due to the pandemic. Data gaps, resource allocation choices, and hospital space considerations are noted situations that have resulted in unintended consequences, reducing the safety of care for this at-risk population. 
Yong E. The Atlantic. 2020;September.
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.
Dolan J, Mejia B. Los Angeles Times. 2020;July 24.
Worker safety has ramifications for patient care in both routine and crisis situations. This story highlights a testing gap that has the potential to degrade efforts to minimize the spread of COVID-19 in nursing homes: the lack of coronavirus testing of inspectors visiting the facilities to assess infection prevention readiness.  
Honderich H, Popat S. BBC News, Washington. 2020;Jul 27.
Omissions in standard procedure contribute to harm in a wide range of care environments. This news story highlights system failures associated with inmate testing prior to a transfer that resulted in a prison coronavirus outbreak. The story highlights how conditions, activities and design of the facility are contributing to the outbreak. 
Abelson J, Tran AB, Kornfield M, et al. The Seattle Times. 2020;July 13.
The COVID-19 pandemic has impacted health care delivery in a variety of settings. This magazine story shares the results of interviews with university students across the country to identify weaknesses found in college health center processes that have resulted in care delays and misdiagnosis.
Khazan O. The Atlantic. 2020;July 6.
Residential care facilities have been particularly challenged by COVID-19. This article outlines how lack of access to protective equipment, staff training, accurate statistics and effective employee testing have hindered the ability of nursing homes to protect patients and staff from the virus.    
Girion L, Levine D, Respaut R. Reuters. 2020;June 9.
The COVID-19 pandemic has disrupted the supply of protective equipment, medical devices and medications. This article discusses how economics contribute to drug shortages and highlights the specific impact on access to the opioids essential for providing safe care for hospitalized patients with COVID-19.

People’s Pharmacy.  Show 1209. April 28, 2020.

Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in medicine. She draws from both general and COVID-19 pandemic care experiences to illustrate the difficulties involved in measuring, understanding and improving patient safety.

Malone P, Kamb L. Seattle Times. March 30, 2020.

False negative test results can contribute to misdiagnosis, treatment delays, and patient and family trauma when the true diagnosis emerges. This story illustrates the impact of diagnosing an emerging disease when missteps can result in conditions that present dangers to the patients and the communities in which they live.