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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 46 Results
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
US Food and Drug Administration. October 7, 2021.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2020.
This reoccurring report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Older reports are also available.
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
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.
Beil L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Baker M.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Wei S; Allen M; Pierce O.
Transparency has been advocated as a key element of safe, patient-centered care, but data on individual performance has not been made widely available. This database compiles the death and complication rates of surgeons performing eight specific elective procedures on Medicare patients to provide performance records and enhance patient decision-making when selecting surgeons.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.
St Paul, MN: Minnesota Department of Health; 2015.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Gubar S.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Kowalczyk L.
Reporting on an incident involving administration of an inappropriate dye which led to a patient's death, this newspaper article reveals how cognitive biases may have played a role and steps the hospital took to prevent similar errors. Six Massachusetts hospitals have launched a pilot program for early apology and resolution in an effort to enhance patient satisfaction and safety.
O'Donnell J.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Department of Health of Western Australia, Patient Safety Directorate. Perth: Department of Health WA; 2011.
This report shares the 2010-2011 results of Western Australia's sentinel event reporting program. Patient suicide is the highest recorded sentinel event. The data is placed in the context of the overall data collected since the program's launch in 2003.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.