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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 27 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.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.

London, England: NHS England; August 2022.

Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizational learning. This framework will replace the current method used by the UK National Health Service (NHS) to support overarching patient safety strategic aims for the agency.

Sentinel Event Alert. Nov 10 2021;(64):1-7.

Health care disparities are emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

American College of Emergency Physicians, National Association of Emergency Medical ServicesAnn Emerg Med. 2021;78(3):e37-e57. 

Emergency medical services (EMS) are often provided in stressful situations that require an orientation to safety to keep patients and staff from harm. This policy statement outlines components of an EMS safety orientation that rests on an established culture of safety in the field.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
Sentinel Event Alert. 2010:1-3.
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk and to promote rapid adoption of risk reduction strategies. This newly released alert focuses on violence in the health care setting, noting increasing rates of violent crimes such as assault, rape, and homicide, which are consistently among the top 10 types of sentinel events reported. Controlling access is viewed as a key protection strategy, and the alert also outlines techniques for identifying violent individuals and for training staff in violence management. The alert summarizes a series of suggested actions that will allow organizations to safeguard against these events. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.
NHS Improvement. July 2, 2019.
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.
Sentinel Event Alert. 2018:1-8.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Sentinel Event Alert. 2017;57:1-8.
The Joint Commission issues sentinel event alerts to highlight commonly reported, novel, or previously unrecognized safety concerns and make recommendations for how to address these critical safety issues. This newly released alert emphasizes the link between leadership and a positive safety culture. Leaders can model a nonpunitive approach to error reporting and investigation, and they should ensure that unprofessional or intimidating behavior is not tolerated. The alert recommends periodic measurement of safety culture using a validated tool such as the AHRQ Hospital Survey on Patient Safety Culture or the Safety Attitudes Questionnaire. Safety assessments should then be used to inform team training and quality improvement efforts. A past PSNet perspective discussed the role of leadership in patient safety.
US Department of Health and Human Services; Centers for Medicare & Medicaid Services.
Poor safety culture and lack of available resources to provide high-quality care can hinder safety in long-term care facilities. This set of regulations will revise requirements for long-term care facilities in areas such as clinical practice standards, service delivery, patient-centeredness, and infection control. The deadline for officially submitting comments on the proposed rule was September 14, 2015.
Irving, TX: American College of Emergency Physicians; 2014.
This guidance recognizes risks associated with emergency medical services and provides recommendations to support the implementation of a safety culture in this setting.

Sentinel Event Alert. August 24, 2011;47:1-4. (revised February 2019).

The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues and stimulate innovative approaches to addressing these threats. The overuse of diagnostic imaging, particularly computed tomographic (CT) scans, poses patient safety risks due to excess radiation exposure. More than 70 million CT scans are performed in the United States every year, and the radiation exposure from these scans may lead to thousands of cancer-related deaths. This alert reviews specific strategies organizations should take to minimize radiation risks, including educating physicians on appropriate test utilization, standardizing equipment and radiation dosage, and promoting a culture of safety. An AHRQ WebM&M commentary discusses factors that may contribute to overutilization of diagnostic imaging, with consequent short- and long-term risks to patients.
Mueller BU, Neuspiel DR, Fisher ERS, et al. Pediatrics. 2019;143:e20183649.
This updated policy statement from the American Academy of Pediatrics reviews the epidemiology of medical errors in children, examines unique issues in safety for pediatric patients, and discusses specific approaches to improving safety in pediatrics. The article emphasizes the responsibility of pediatricians to be familiar with patient safety concepts and techniques, and the importance of establishing a culture of safety in both inpatient and outpatient settings. The article concludes with a series of specific recommendations for advancing the science of patient safety within the field of pediatrics.
Improvement AC of O and GCC on PS and Q. Obstet Gynecol. 2009;114:1424-7.
In this piece, the American College of Obstetricians and Gynecologists emphasizes principles and objectives for patient safety in obstetrics and gynecology practices. The guidelines include encouraging a safety culture, reducing surgical errors, improving communication with patients and providers, and prioritizing safety.

Sentinel Event Alert. August 27, 2009;(43):1-3.

Despite the past decade's focus on improving patient safety, most health care organizations are still striving to achieve high reliability status—consistently providing high quality care while minimizing adverse events. In this sentinel event alert, the Joint Commission calls for senior health care leaders to establish a culture of safety within their organizations, use just culture principles to establish transparent and fair policies for addressing errors at the sharp end, and maintain robust structures for analyzing and responding to adverse events. Specific suggested actions include involving hospital boards and patients in safety efforts and making safety performance an explicit part of the evaluation for leaders. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys. This Sentinel Event Alert was retired in March 2017. Please review The essential role of leadership in developing a safety culture for updated recommendations.
US Department of Health and Human Services; Agency for Healthcare Research and Quality; Federal Register. November 21, 2008;73:70731-70814.
This final rule outlines how to become a Patient Safety Organization (PSO), and supports AHRQ action to receive applications from qualified entities that wish to become PSOs. 
Sentinel event alert. 2008:1-3.
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these strategies is then assessed on Joint Commission site visits at health care organizations nationwide. This newly released sentinel event alert focuses on intimidating and disruptive behaviors and the role they play in the costs, quality, safety, and satisfaction of care delivered. The alert outlines existing Joint Commission requirements and provides a series of suggested actions that include educational programs, "zero tolerance" policies, and clear processes for detecting, reporting, and documenting all instances of such unacceptable behavior.
U.S. Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, House of Representatives, Subcommittee on Oversight and Investigations. 109 Congress, 2nd sess June 15, 2006. Washington, DC: US Government Printing Office; 2007.
These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.