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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 206 Results
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October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can endure over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition. 

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. 

Rabbitt M. Prevention Magazine. April 9, 2020.

Diagnosis in women is complicated by cultural norms, lack of research on medical conditions affecting women, and implicit bias. The article outlines conditions that are likely to be misdiagnosed in women such as heart disease and breast cancer. The author shares strategies for women to engage in the process to improve diagnostic accuracy.  

Chuck E, Assefa H. NBC News. February 8, 2020.

Maternal morbidity and perinatal harm can be exacerbated due to implicit bias. This story discusses a case of an American Indian/Alaska Native mother and infants whose deaths may have been preventable had her concerns been more effectively addressed. The situation illustrates conditions in the broader indigenous peoples’ community that indicate a lack of respect and patient-centeredness as factors contributing to poor care.
Lintern S. The Independent. November 18, 2019.
Infants are particularly vulnerable to patient safety errors. This article shares preliminary findings of a government investigation into infant deaths at a National Health Service Trust hospital. Initial insights discussed include the lack of a safety culture at the Trust Hospital facilitating the persistence of the problems.
Sutcliffe K. Time Magazine. November 5, 2019.
Experts agree that while some progress has been made since To Err is Human was published in 1999, progress has been frustratingly slow and, in some instances, fleeting. This commentary argues the problem rests with the lack of engagement of human factors engineering experts and the focus on initiatives that don't effectively change the health care system.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Schulte F; Fry E.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
Span P.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.