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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ISMP Cheers Awards.

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Institute for Safe Medication Practices.

The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety. The 2023 awards recognized Susan Donnell Scott PhD for her work focusing on support mechanisms for clinicians involved in medical error.

National Patient Safety Goals.

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The Joint Commission.

The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.

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.

MHA and MHA Keystone Center Annual Reports.

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Okemos, MI: Michigan Health & Hospital Association.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. The achievements noted in the 2022-2023 data review include reduction of MHA Keystone Center PSO members have significantly reduced both fall and blood or blood product events reported to the state patient safety organization reporting system. Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal health.

American Hospital Association–McKesson Quest for Quality Prize.

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American Hospital Association.

This award program recognizes organization-wide commitment to five key goals that support high-quality health care: access, health, innovation, affordability, individual as partner. The deadline for submitting an application for the 2024 award cycle has passed.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Enhancing resident education by embedding improvement specialists into a quality and safety curriculum.

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Levy KL, Grzyb K, Heidemann LA, et al. J Grad Med Educ. 2023;15:348-355.

The quality improvement and patient safety (QIPS) curriculum is increasingly being added to resident education, but implementation and quality of these programs varies. In this study, continuous improvement specialists (CIS) were embedded in resident teams to create an A3, a quality improvement tool. A key component to the QIPS curriculum was aligning resident projects with quality improvement efforts already underway in the department.

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

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Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.

Understanding the root cause analysis process to increase safety event reporting.

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Dudley KA. AORN J. 2023;117:399-402.

Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning and improvement after a sentinel event. This article posits why perioperative nurses may not report problems to avoid engagement in RCA activities. Increasing nurse awareness of RCA as a multidisciplinary and systems-focused improvement method is a suggested educational tactic to increase nurse RCA participation.

In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.

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Yang CJ, Saggar V, Seneviratne N, et al. Jt Comm J Qual Patient Saf. 2023;49:297-305.

Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

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Carthey J. BMJ Qual Saf. 2023;32:441-443.

The Measurement and Monitoring of Safety Framework (MMSF) draws on principles of high-reliability to increase patient safety at the organizational level. This commentary describes the Canadian Learning Collaborative’s experience implementing MMSF and highlights several key elements for successful implementation.

Systems approach to suicide prevention: strengthening culture, practice, and education.

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Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.

Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.

Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades?

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Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.

Adverse events in patients of color continue to be connected with systematic racism and biases. This report summarizes the distribution of patient safety events among Black and Hispanic patients across 2,019 Leapfrog patient safety graded hospitals and found that they experience adverse surgical events at a higher level than white patients.

ISMP Survey on the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

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Institute for Safe Medication Practices. May 2023.

The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2022-2023 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission closes June 30, 2023.

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

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Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.

The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.

Challenge Competition: Impact of Patient Safety Tools.

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Agency for Healthcare Research and Quality, Rockville, MD. 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

Eliminating central line associated bloodstream infections in pediatric oncology patients: a quality improvement effort.

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Willis DN, Looper K, Malone RA, et al. Pediatr Qual Saf. 2023;8:e660.

Reducing healthcare-associated infections (HAIs) is a patient safety priority. This article describes the development of a quality improvement initiative to reduce central line-associated bloodstream infections (CLABSI) on one pediatric oncology ward. The initiative included four key interventions – huddles to improve identification of patients at risk for CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition (HAC) rounding cards to prompt discussions on central line functionality. This multimodal approach led to a significant reduction in CLABSI rates between 2020 and 2021, and an increase in CLABSI-free days.

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period.

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Birkeli GH, Ballangrud R, Jacobsen HK, et al. BMJ Open Qual. 2023;12:e002247.

Interprofessional huddles and voluntary reporting of incidents and near-misses are ways to improve patient safety and safety culture. This Norwegian post-anesthesia care unit (PACU) implemented a voluntary incident reporting method, Green Cross (GC), that includes daily team huddles to discuss reports from the previous 24 hours. Three years after implementation, staff reported GC was still active, but use has declined, particularly during the COVID-19 pandemic. They also reported a desire for increased follow up and physician involvement.

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic.

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Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.

Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

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Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

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