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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 137 Results

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

Save to Library

Washington DC; Office of Senator Mark Warner: November 25, 2022.

There is lack of consensus concerning the need for increased system and policy attention on cybersecurity challenges as a threat to patient safety. The report suggests modifications within the federal government infrastructure to increase attention to cybersecurity as a safety issue, public/private partnership opportunities, and policy development to reduce the potential for cyberattacks that impact care delivery.

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

Save to Library

Washington DC: United States Government Accountability Office and National Academy of Medicine; September 2022. Report no. GAO-22-104629.

Machine learning is a subset of artificial intelligence that has potential to improve diagnosis. This report examines the value of existing machine learning diagnostic technologies and discusses concerns and policy impacts of their use over time. The authors suggest evaluation, data access and collaboration as strategies to enhance policy supporting technology development and safety.

Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption of Artificial Intelligence in Medical Diagnosis.

Save to Library

Adler-Milstein J, Aggarwal N, Ahmed M, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2022.

Artificial intelligence can support care through effective integration of computerized diagnostic decision support (DDS) systems. This report examines four foci for successful DDS use: why clinicians use it, what tools support it, how it is used, and the way it is accessed. Policies are introduced as a tactic to support unbiased and safe implementation of decision support systems.

Curated Libraries

Diagnostic Safety

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.

Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning.

Save to Library

de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.

The global effect of harm associated with preventable drug errors is substantial. This report discusses the human and financial impact of medication errors in a variety of countries, prescribing process improvement, established efforts to enhance medicine use safety, and avenues for national medication safety achievement.

Examining the Status of VA’s Electronic Health Record Modernization Program.

Save to Library

US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

Save to Library

Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204.

Problems with clinician order delivery can result in harmful care delays. This report discusses how an electronic health record (EHR) system sent thousands of requests for medical care in a large health system to no location rather than to the intended site for care. These misattributions contributed to 142 patient safety events. The analysis highlighted factors contributing to the EHR misdistribution of orders and shared concerns that the organization’s approach to reduce the risk for misrouted orders lacks effectiveness.

Top 10 Patient Safety Concerns 2022.

Save to Library

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

Save to Library

Washington, DC: VA Office of Inspector General; March 17, 2022.

Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.

Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.

Save to Library

Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.

The emergence of telemedicine during the COVID-19 pandemic has situated it to become an accepted model for health service provision despite safety concerns. This white paper discusses a 6-item framework to enhance the safety, equity, and person-centeredness of telemedicine and recommendations for embedding safer methods into telemedicine practice.

Weight-based Medication Errors in Children.

Save to Library

Farnborough, UK: Healthcare Safety Investigation Branch; February 2, 2022.

Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing, and administration accuracy. This report examines factors contributing to a computation mistake that resulted in a child receiving a 10-fold anticoagulant overdose over a 3-day period. Areas of focus for improvement include use of prescribing technology, and the double-check as an error barrier.

Targeted Medication Safety Best Practices for Hospitals.

Save to Library

Horsham, PA: Institute for Safe Medication Practices; 2022.

This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications.

Curated Libraries

Medication/Drug Errors

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...

Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.

Digital Clinical Safety Strategy

Save to Library

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.

Improving Telediagnosis--a Call to Action: Final Project Findings.

Save to Library

Graber ML, Schrandt S. Evanston, IL: Society to Improve Diagnosis in Medicine; September 8, 2021.

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.

Curated Libraries

Maternal Safety

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, collaborative initiatives, teamwork, and trigger tools.

Ethics & Governance of Artificial Intelligence for Health.

Save to Library

Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021. ISBN: 9789240029200

Advanced computing technologies can help or hinder safe care. This guidance summarizes ethical concerns and risks stemming from the influx of artificial intelligence (AI) into decision making throughout health care. The report provides 6 tenets to guide AI implementation worldwide and shares governance recommendations to ensure the clinical and public health impacts of AI are equitable, responsible and safe.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

Save to Library

Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Algorithmic Bias Playbook.

Save to Library

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users