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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Dying for Care.

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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.

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

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Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

How nursing homes’ worst offenses are hidden from the public.

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Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.

Agency information collection activities: Nursing Home Survey on Patient Safety Culture Database; comment request.

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Agency for Healthcare Quality and Research. Fed Register. September 21, 2021;86:52471-52473.

This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Nursing Home Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Phony diagnoses hide high rates of drugging at nursing homes.

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Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.

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Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

Harmed Patient Alliance.

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United Kingdom.

Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a deeper understanding of the factors contributing to lack of response to concerns to enhance existing processes.

Think health care workers are tested often for the Coronavirus? Think again.

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Wamsley L. National Public Radio and WBUR. December 7, 2020.

Testing for COVID-19 is a core public safety strategy for pandemic management. This news story discusses how a lack of health care workers’ virus status knowledge could contribute to spread. Barriers inherent to a universal testing strategy include operational challenges, patient testing volume, and availability of health care workers to provide care during the pandemic should clinicians test positive.

Nurses and doctors sick with COVID feel pressured to get back to work.

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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.

When COVID-19 hit, many elderly were left to die.

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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.

How the pandemic defeated America.

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Yong E. The Atlantic. September 2020

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.

As coronavirus ravaged nursing homes, inspectors were not being tested.

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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.

The U.S. is repeating its deadliest pandemic mistake.

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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.

Care Compare.

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Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.

A nursing home’s 64-day Covid siege: ‘They’re all going to die’.

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Barker K. New York Times. 2020;June 10.

This feature story describes the COVID-19 experience at one nursing home and discusses how the infection progressed through the institution and challenged effective care management. Family perceptions of process and care problems provide important insights for improvement.

Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19.

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National Academy of Medicine. April-June 2020.

Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. This webinar series covered topics such as keeping nursing home residents and the staff that care for them safe, practice integration in skilled nursing facilities, communication and collaboration in times of crisis, testing and SARS-CoV-2 transmission prevention tactics.

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

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Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-576R.

This US Government Accountability Office (GAO) report highlights the chronic shortfalls in nursing home infection control programs. The GAO analyzed survey data from the Centers for Medicare & Medicaid Services (CMS) and found 82% (13,299) of nursing homes surveyed were cited in one or more years between 2013-2017 and in each individual year, 40% of nursing homes had infection control and prevention deficiencies that continued through 2018 and 2019. While the majority of the citations did not indicate harm to nursing home residents and were rarely associated with enforcement actions, the GAO intends to examine CMS oversight of infection and control in the near future. In light of the COVID-19 pandemic, these findings are particularly concerning.

Nursing home workers warned government about safety violations before COVID-19 outbreaks and deaths.

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Ellis B, Hicken M. CNN. May 14, 2020.

Long-term care and skilled nursing facilities care for a patient population particularly vulnerable to COVID-19 infection. This article discusses an analysis of a large nursing home system and gaps in its workforce safety program. Problems highlighted included communication practices that fall short of what is needed to assure staff safety as they care for nursing home residents.

People with disabilities fear pandemic will worsen medical biases.

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Shaprio J. National Public Radio. April 15, 2020.

Access to care has been strained by the COVID-19 pandemic. This radio segment discusses how implicit biases can affect care of patients with disabilities. It highlights how preconceptions about this patient population could limit their access to treatments should they become ill.

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