Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Commonly Searched Resource Types
Displaying 1 - 17 of 17 Results

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.

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.

ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.
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.
Park A.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Beck DL. ASH Clinical News. December 1, 2018.
This article provides an overview of efforts to understand and improve patient safety and covers topics such as the epidemiology of error, its impact on the individuals involved, and the importance of transparency in healing and learning from mistakes.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious patient safety incidents at a health care institute dedicated to treating heart problems in children and the cultural and individual provider issues that perpetuate unsafe care.

Wachter R, Kaplan GS, Gandhi T, et al. Health Affairs Blog. June 22, 2015.

Transparency is recognized as a key element of safe, patient-centered care. This article offers insights from patient safety experts on how transparency can augment patient safety, barriers such as discomfort with disclosure and fears about negative consequences, and steps leaders can take to achieve greater transparency in their organizations.
Judd A. The Atlanta Journal-Constitution. November 20, 2011.
Discussing a case of patient suicide, this news article explores the lack of transparency around patient safety incidents in the state of Georgia.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.