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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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Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...

Ofri D. New York Times. January 5, 2021. 

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care. 
Arditi L. Peoples Public Radio. December 3, 2019.
Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors

ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.

Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
Canadian Medical Protective Association; CMPA.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
Young A, Kelly J, Schnaars C, et al. USA Today.
Incidence of maternal harm is increasing in the United States. This news article series reports on factors that contribute to preventable maternal mortality, such as omission of recommended care processes, lack of patient-centeredness, and missed or delayed diagnoses of serious conditions.
Landro L. Wall Street Journal. March 28, 2011.
This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.

Bogdanich W. New York Times. January 24, 2010:A1.  

First in a series on medical radiation, this news feature investigates patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Landro L. Wall Street Journal (Eastern edition). December 23, 2008;D2.
Emphasizing the importance of safe device use to prevent patient harm, this article reports on the top 10 technology hazards in hospitals according to ECRI Institute's annual list, which includes alarm hazards, retained fragments, misleading displays, and surgical fires.
Rozovsky FA, Gilk TB, Latina RJ. Materials management in health care. 2006;15:18-23.
This article discusses risk management in magnetic resonance imaging facilities and the use of root cause analysis to inform risk management methodologies.
Stein R; USP; United States Pharmacopeia
This article reports on an analysis of data collected by United States Pharmacopeia's voluntary reporting program that found medication errors are seven times more likely to occur during radiological procedures.