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 - 19 of 19 Results

Mothers face broken addiction treatment system.

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D'Ambrosio A. MedPage Today. March 31, 2023.

Maternal health is challenged across social strata but notably amongst populations of color, economic disparity, and social minority. This article discusses barriers mothers face trying to manage substance use disorders during pregnancy and after birth due to system problems and stigma.

Maternal Safety and Perinatal Mental Health

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Perspective on Safety March 29, 2023

This piece focuses on perinatal mental health and efforts to improve maternal safety.

In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health

Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery

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Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

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Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.

Gaps in care for psychologically vulnerable patients can result in harm to family members and self-harm. This report examines organizational failures in responding to staff and clinical leaders’ concerns regarding access, triage, and care continuity for mental health patients. Recommendations for improvement include same-day access to appropriate specialty care, medication management, and risk documentation.

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

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Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.

Patient Safety Concerns and the LGBTQ+ Population

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Perspective on Safety February 1, 2023

This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.

In Conversation with Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population

Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

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Washington DC; Office of Senator Mark Warner: November 25, 2022.

There is lack of consensus concerning the need for increased system and policy attention on cybersecurity challenges as a threat to patient safety. The report suggests modifications within the federal government infrastructure to increase attention to cybersecurity as a safety issue, public/private partnership opportunities, and policy development to reduce the potential for cyberattacks that impact care delivery.

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.

The REPAIR Project.

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University of California San Francisco, San Francisco, CA.

Systemic racism reduces the effectiveness and safety of the care people of color receive. The REPAIR (REParations and Anti-Institutional Racism) Project is examining the impact of racism on Black individuals in medicine and the sciences. Each year of the 3-year initiative is focused on a distinct theme: medical reparations, medical abolitionism and decolonizing the health sciences.

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

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Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.

Health inequities are receiving increased attention as a patient safety issue. This book examines the persistent problem of systemic racism on the health of Black patients. It summarizes the evidence on how racism affects health care and discusses strategies for improvement such as reducing gaps in implicit bias content in curriculum.

Antifatness in the surgical setting.

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Andreou A. Scientific American. May 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.

Nurses: Guilty verdict for dosing mistake could cost lives.

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Loller T. Associated Press. March 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Curated Libraries

Maternal Safety

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, collaborative initiatives, teamwork, and trigger tools.

Black or 'other'? Doctors may be relying on race to make decisions about your health.

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Smith J, Spodak C. CNN. April 25, 2021.

Race-adjusted decision making tools perpetuate the potential for diagnostic error and care delay. This article examines race correction as a form of bias in health care and discusses efforts to reduce the use of race-adjusted algorithms.

Recognizing the importance of whistleblowers in healthcare.

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O'Neill N. Nursing (Brux). 2021;51:54-56.

Individuals who express concerns can identify latent conditions that degrade safety in health care. This article examines this behavior in the context of the COVID pandemic and staff safety. The author highlights instances of peer and organizational retaliation against whistleblowers.

Racial bias in pulse oximetry measurement.

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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.

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

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London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up.

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Lintern S. The Independent. January 15, 2020.

The Francis report is a primary example of a large-scale examinations of health care system failure. This story highlights that transparency, duty of candor and whistleblowing protections have improved since the report’s release a decade ago but that more work needs to be done to fully embed a culture of safety throughout the United Kingdom National Health Service.

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