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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 - 5 of 5 Results

Sentinel Event Alert. June 22, 2022;(65):1-7.

A clinician's knowledge of an existing condition can implicitly affect treatment recommendations and decisions. This alert highlights the presence of diagnostic overshadowing as a type of bias that is prone to affect disadvantaged or stigmatized patient populations. Listening training programs, improved use of patient data review, and assessment techniques are recommended to trigger diagnostic curiosity to encourage complete decision-making methods when serving patients.

Quick Safety. October 6, 2020;55:1-4.

Telehealth benefits, barriers, and challenges have become more apparent due to its increased use due to COVID-19 physical distancing and quarantine measures. This report summarizes actions to enhance the safety of telehealth. These actions include proactive determination of metrics and a process for tracking activities, use of protocols for telehealth visits, staff training, and orientation to effective care standards and protocols.     
George J, Elwy AR, Charns MP, et al. Jt Comm J Qual Patient Saf. 2020;46:270-281.
This retrospective study explored whether staff perceptions of organizational culture at the Department of Veterans Affairs (VA) were associated with large-scale adverse events. The authors found an inverse association between a supportive organizational culture and the incidence of large-scale adverse events. Results suggest that in hospitals with reciprocal engagement (i.e., staff perceptions that the organization cares about the employee), staff are more likely to adhere to safety practices that prevent or mitigate large-scale adverse events.
Blustein J, Wallhagen MI, Weinstein BE, et al. Jt Comm J Qual Patient Saf. 2019;46:53-58.
The authors of this narrative review propose that hearing loss be included in the patient safety conversation, noting that poor hearing has been linked with poor outcomes including higher rates of hospitalization, increased length of stay, and greater likelihood for 30-day hospital readmission. The authors suggest that hearing loss be a priority item on safety agendas put forward by organizations such as The Joint Commission.