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 93 Results

Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.

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Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.

Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.

Toxic leadership and its relationship with outcomes on the nursing workforce and patient safety: a systematic review.

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Labrague LJ. Leadersh Health Serv (Bradf Engl). 2023;Epub Oct 9.

Leadership behaviors have an important impact on the workforce and work environment in both positive and negative ways. This review summarizes how toxic leadership impacts the nursing workforce and patient safety. Within the patient safety theme, toxic leadership was significantly associated with increased falls, nosocomial infections, and medication errors.

Bringing the equity lens to patient safety event reporting.

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Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.

Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Smart Healthcare Safety.

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Plymouth Meeting PA, ECRI. 2019-2023.

A wide variety of considerations must converge to inform an understanding of system vulnerabilities and the application of strategies to address them. This series of webinars covers a range of topics affecting the reliability of the health care environment. A recent presentation discussed the “5 rights of medication safety.”

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

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Wu AW, Papieva I, Sheridan S, et al. J Patient Saf Risk Manag. 2023;28:147-152.

True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.

A scoping review exploring the confidence of healthcare professionals in assessing all skin tones.

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Harrison J. Br Paramed J. 2023;8:18-28.

Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones. Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.

Vital signs: maternity care experiences — United States, April 2023.

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Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.

Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis.

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West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.

Covering Health: Patient Safety.

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HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2023.

The role media plays in raising awareness of patient safety issues in a timely and appropriate manner is consequential. This series instructs writers to communicate on medical error and quality topics in a high-quality professional style with discernment of the content being reported. Series contributions include discussions on medical error statistics and outpatient surgery rankings.

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.

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Mann B. Health Shots. National Public Radio. August 7, 2023.

Stigma against behavioral health conditions is known to affect the quality of care relationships and therapeutic actions. This news article discusses the limited use of methadone and other medications as strategies to assist in the care and recovery of opioid use disorder patients.

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2023.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety.

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James C, Singh K, Valley TS, et al. Rockville, MD; Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0040-4-EF.

As artificial intelligence (AI) and machine learning (ML) become established in health care, it is critical for clinicians and patients to effectively collaborate to use AI safely. This Issue Brief adds to a series of diagnostic-focused reports and presents a framework to guide patients and clinicians on working as team members when using AI and ML to make diagnostic decisions.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

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McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.

Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

Patient safety in palliative care at the end of life from the perspective of complex thinking.

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Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Healthcare (Basel). 2023;11:2030.

Adverse events in palliative care can include inappropriate pain management, preventable hospital (re)admissions, falls, and pressure injuries. This paper outlines ways palliative care is not always received timely, the uniqueness of patient safety within palliative care, and how to raise awareness of both of these issues for healthcare providers, educators, and patients and families.

Advancing Diagnostic Excellence in Maternal Health Care.

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Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Irvine, CA: Arnold and Mabel Beckman Center: 2021-2023.

These free workshops discussed current challenges in diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities, cancer misdiagnoses and problems in the care of older adults that affect diagnosis.

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

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Washington, DC: VA Office of the Inspector General; June 28, 2023. Report no. 22-02725-132.

Delays in emergency care provision can contribute to patient harm. This analysis examined an instance of cardiopulmonary resuscitation (CPR) delay and the poor response once the emergency was identified at an outpatient clinic. System-level issues flagged include incomplete incident records and follow up. Staff training, emergency notification, CPR process compliance, and debrief results completion were among the recommendations for improvement.

Health literacy and systemic racism—using clear communication to reduce health care inequities.

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Coleman C, Birk S, DeVoe J. JAMA Intern Med. 2023;183:753-754.

Low personal health literacy is associated with increased post-discharge adverse events and health inequities. This commentary describes organizational strategies to improve health literacy, including elimination of jargon in written and spoken communications and assessment of health professionals’ patient-centered communication tools.

The challenge of risk prevention in home healthcare-an interview study with nurses in municipal care.

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Lekman J, Lindén E, Ekstedt M. Scand J Caring Sci. 2023;Epub May 24.

Risk reduction in home health faces unique challenges. In this study of registered nurses providing home health, challenges included finding a balance between the patient's autonomy and ensuring a safe environment, building relationships with the patient and family, and gaps between resources and requirements.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

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