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 146 Results

A deadly epidural, delivered by a doctor with a history of mistakes.

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Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

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Westwood R. Kaiser Health News. January 12, 2023.

Lack of access to obstetric care impedes safe treatment for mothers. This story describes challenges one mother experienced in finding care during a miscarriage due to abortion policies and the steps she and her family took to manage her condition.

ER doctors misdiagnose patients with unusual symptoms.

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Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

During in-flight emergencies, sometimes airlines’ medical kits fall short.

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Ramachandran V. Kaiser Health News. January 6, 2023.

Inadequate equipment and personnel training degrade the reliability of individuals to provide safe care in an emergency. This article discusses inconsistent preparedness throughout commercial aviation to support care during an in-flight medical situation; it suggests federal oversight of medical kits may help to ensure their completeness and improve the potential for safety should care be required.

From heart disease to IUDs: how doctors dismiss women’s pain.

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Bever L. Washington Post. December 13, 2022.

Gender and racial bias contributes to inadequate and delayed care. This story focuses on women who have experienced harm due to their pain concerns being marginalized or dismissed.

Her child was stillborn at 39 weeks. She blames a system that doesn’t always listen to mothers.

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Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long?

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McFarling UL. STAT. November 1, 2022.

Evidence is building to delineate the effect of systemic bias on care safety. This article recognizes the flaws of pulse oximeters on patients with darker skin, gaps in the literature base, and the work of regulatory bodies to consider redesign and regulation of the device to address bias.

Walgreens will stop judging its pharmacy staffers by how fast they work.

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Kaplan A. NBC News. October 27, 2022.

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.

Medicare fines for high hospital readmissions drop, but nearly 2,300 facilities are still penalized.

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Rau J. Kaiser Health News. November 1, 2022.

The COVID-19 pandemic necessitated adjustments in activities across health care to address patient care and staffing demands. This news article discusses COVID-19’s impact on the hospital-acquired condition reduction program, and how 43 percent of US hospitals failed to reach readmission goals.

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

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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.

‘They can’t ignore us any more’: five women on long Covid and medical misogyny.

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Lu D. The Guardian. October 18, 2022.

Disrespect for women around the world is known to occur in health care that contributes to diagnostic delay and lack of trust in the system. This news article describes challenges met by 5 women patients seeking diagnosis and treatment for long COVID.

People of color with long COVID face uphill battle to be heard.

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Farah T. Scientific American. September 22, 2022.

Gaslighting women and patients of color is known to occur in health care for both common and emerging conditions. This news article describes challenges met by a patient seeking diagnosis and treatment for long COVID.

Embedded bias: how medical records sow discrimination.

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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.

When medical error becomes personal, activism becomes painful.

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Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.

New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors.

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Lovelace Jr, B. NBC News. September 7, 2022.

Look-alike sound-alike packaging is a known risk factor in medication errors. This news story discusses how a questionable design decision to use similar cap colors for the latest COVID boosters creates potential for administration errors.

Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them.

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Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death.

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Mills M. The Guardian. September 3, 2022

Families experiencing medical error can harbor frustration with the system but also with themselves for allowing care mistakes to take their loved one. This first-person account shares the story of a mother’s loss of a daughter to sepsis. The memoir illustrates how lack of respect for a family’s concern contributed to the incident.

Abortion bans have consequences for wanted pregnancies, too.

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Feibel C. Consider This. National Public Radio. August 3, 2022.

Maternal complications risk the health of both mothers and babies, and a variety of circumstances create challenges to this complex care process. This article describes delays in care for a pregnant patient due to legal and policy concerns that threatened the life of the mother.

Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin.

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West S. Kaiser Health News. August 5, 2022.

The article highlights skin cancer identification problems in patients of color. The author outlines educational tactics to alert clinicians and patients of the potential for misinterpretation of abnormalities in dark skin to reduce misdiagnosis.

A California man’s ‘painful and terrifying’ road to a Monkeypox diagnosis.

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Fortiér J. Kaiser Health News. August 4, 2022.

Lack of familiarity with disease is known to contribute to missed and delayed diagnosis. This story highlights system and individual challenges for patients presenting with monkeypox symptoms to get the diagnosis and care they need.

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