The PSNet Collection

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.

Displaying 1 - 6 of 6 Results

Broken, fragmented health-care system failed daughter who died by suicide.

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Klowak M. CBC News. March 9, 2020.

System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.

Their kids died on the psych ward. They were far from alone, a Times investigation found.

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Karlamangla S. Los Angeles Times. December 1, 2019.

Patient suicide is considered a sentinel event. This feature shares an examination of approximately 100 preventable deaths in the State of California over a decade. An examination of the case records identified breakdowns in care processes such as lack of training, low staffing and human error.

Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences.

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Woodruff E. Baltimore Sun. June 9, 2017.

Psychiatric patients are vulnerable to particular safety hazards. This news article reports on unintended consequences associated with a strategy to help patients adapt to being discharged home by providing passes for them to adjust to independent living.

Hospital mistakes kept secret.

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Judd A. The Atlanta Journal-Constitution. November 20, 2011.

Discussing a case of patient suicide, this news article explores the lack of transparency around patient safety incidents in the state of Georgia.

Learning from the best.

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Grantham D. Behavioral healthcare. 2010;30:22-4.

This news article highlights an award-winning addiction treatment center’s strategy to embrace patient safety improvement.

Hospital infections hard to gauge.

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This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated infections in Pennsylvania.

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