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.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.
Systemic weaknesses challenge safe care in Veterans Affairs health systems facilities. This report analyzed a patient suicide at one medical center and determined contributors to the failure. This report shares recommendations to address deficiencies including improved communication across the care continuum and reliably acting on root cause analysis results.
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