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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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Displaying 1 - 20 of 56 Results

Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments is January 26, 2023.

Boston, MA; Institute for Healthcare Improvement: December 2022.

Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of effort to reduce inequity in health care: access, workforce, social and structural drivers, and quality and safety.

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.
Perspective on Safety December 14, 2022

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Perspective on Safety December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.

Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.

US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.

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.

Farnborough, UK: Healthcare Safety Investigation Branch; 2022. HSIB Report no. NI-005831

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.

US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.
Perspective on Safety August 5, 2022

Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie Health. We spoke with her about the emergence of application-based tools used for healthcare and the patient safety issues surrounding the use of such tools.

117th Cong, 2d Sess (2022)

Strengthening diagnostic error research and training can lead to sustained diagnostic improvement. Expanding upon legislation introduced in 2020, the “Improving Diagnosis in Medicine Act of 2022” would establish research centers of diagnostic excellence, an interagency council on improving diagnosis in healthcare, and fellowship and training grants in diagnostic safety, as well as convene an expert panel on diagnostic error measurement and data collection and prioritize stakeholder engagement across all activities.

Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022.  ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.

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.

Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.