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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 72 Results
Curated Libraries
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.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Brody JE. New York Times. 2020.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns. 

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.  
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Haun N, Hooper-Lane C, Safdar N. Infection control and hospital epidemiology. 2016;37:1367-1373.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
Medical care overuse is emerging as a patient safety hazard that can result in harms such as unneeded testing and poor end-of-life care. This collection of articles and audiovisual resources explore factors that contribute to medical care overuse and its impact on patients and their families.
Hobson K.
Diagnostic error has recently gained recognition as an important patient safety concern. This news article relates the experiences of patients who were misdiagnosed and discusses avenues for improvement such as exploring physician problem-solving behaviors and using trigger tools to detect potential lapses in care.
CDC; Centers for Disease Control and Prevention.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Landro L. Wall Street Journal. August. 8, 2016.

First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
Jauhar S. New York Times. March 3, 2016.
Performance of autopsies, previously considered an essential learning tool for clinicians, has decreased in recent years due to insufficient funding to cover costs and lack of physician endorsement of the practice. This newspaper article provides insights from a physician regarding how the decline in autopsies could affect care and highlights the benefits of autopsies in light of the current emphasis on improving diagnosis.
Rosenthal E.
Raising concerns around the use of armed security guards in health care settings, this newspaper article and companion podcast report on the experience of a patient who disclosed a need for mental health treatment upon arriving at a hospital where staff failed to appropriately address his psychiatric condition and instead treated his physical injuries. The patient became increasingly agitated and hospital security personnel ultimately used weapons to subdue him.
Roe S; King K.
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports discusses the problem of drug interactions, including one patient's experience of severe harm and researchers' use of data mining to identify medication pairs linked to high-risk interactions. The series also includes a list of steps patients can take to reduce risk of harmful interactions between medicines they take.
Frakt A.
Humans are vulnerable to distraction, fatigue, and memory lapses, which can hinder their ability to process information. This newspaper article reports how advanced computing and structured tools like checklists can improve medical care, while cautioning against over-reliance on such strategies.
Brody JE.
Over-the-counter medications are often convenient and cost-effective for patients. This newspaper article discusses how patients' failure to consult a physician or pharmacist, read directions, or adhere to instructions can compromise medication safety and result in unintentional overdoses.