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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 93 Results

Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.

Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-0047-2-EF.

Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians, yet physicians rarely receive feedback on their actions to enhance diagnostic decision making. This publication provides clinicians with tools to assess and calibrate diagnostic performance in support of individual learning and improvement.
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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing and a tendency to blame individuals for problems. This website hosts the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey along with additional materials to assist organizations in using the management tool effectively. It includes a user's guide that explains how to conduct a survey on patient safety in a nursing home and report the results. The resource provides guidance on topics such as data collection, data organization, survey forms, and nursing home staff selection. The 2022 data collection period is now closed.

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

Rockville, MD: Agency for Healthcare Research and Quality; March 2022. 

The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis.

RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergency and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
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, care standardization,teamwork, unit-based safety initiatives, and...
Rockville, MD: Agency for Healthcare Research and Quality; June 2022.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The data submission window for 2022 is now closed.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

Agency for Healthcare Research and Quality. April 2021.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication. The Diagnostic Safety Supplemental Item Set was released in time for the scheduled Fall 2021 MOSOPS data submission.

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.

Harrisburg, PA: Pennsylvania Safety Authority; 2020.

Time pressure can negatively impact critical thinking, information gathering, and communication abilities. This tool builds teamwork and decision-making skills by testing participants as they work through a time-delimited scenario with a sick child to gather clues and determine a diagnosis. 

Circle Up for COVID-19 Training. Center for Medical Simulation.

Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.

Agency for Healthcare Research and Quality (AHRQ). March 2020.

This website provides a report and data repository representing medical offices that administered the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey. Insights on safety culture reflect practices from 1,475 medical offices and more than 18,000 respondents.
Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030.
Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.