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.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 30 and February 1, 2024.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

Uncovering the shocking dangers of misdiagnosis.

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Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.

Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

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Desjardins L. PBS NewsHour. August 29, 2023.

Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.

Preventing home medication errors.

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Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.

Jake Tapper shares harrowing story of daughter's near-fatal misdiagnosis.

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CNN. December 15, 2022.

Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’s misdiagnosed appendicitis and discusses factors associated with the error including lack of concern by staff for her pain and premature closure.

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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.

Unite for Safe Care.

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Patient Safety Movement. September 17, 2021.

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.

CANDOR Webinar Series.

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Patient Safety Movement Foundation. 2021.

The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webinar series introduced the CANDOR process, discussed CANDOR implementation, outlined the importance of organizational readiness assessment for the program, and described actions to sustain CANDOR after it has launched. Speakers include Dr. Timothy McDonald, the originator of the model.

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

COVID-19 Webinars.

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The International Society for Quality in Health Care. March - May 2020.

The COVID-19 pandemic is a worldwide crisis that requires organizations, governments, and individuals to draw from the collective experience and rapidly improve practice. This series of webinars discuss a variety of foci to share experience from the field. Topics covered include human factors engineering, clinician support, and communication.

Unprofessional Behavior Leads to Complications.

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JN Learning. 2020.

Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educational program highlights a study that measured the impact of unprofessional physician behavior on patient care and features Dr. William Cooper and Dr. Gerald Hickson as speakers.

Medical misdiagnosis: more common than you think.

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Kast S. "On the Record." WYPR. October 31, 2017.

Diagnostic error continues to motivate improvement efforts in patient safety. This audio news segment discusses challenges that contribute to misdiagnosis, strategies to prevent diagnostic errors, and recommendations for patients to reduce risks such as preparing for appointments and asking questions.

Making health care safer. Think sepsis. Time matters.

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CDC; Centers for Disease Control and Prevention.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

A Conversation on Transparency and Patient Safety.

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ProPublica. Kaiser Family Foundation's Barbara Jordan Conference Center, Washington, DC; March 23, 2016.

Reporting mechanisms to share performance data with consumers have been launched in an effort to increase transparency, but there are criticisms regarding their usefulness. In response to the launch of the Surgeon Scorecard, this session featured a discussion on causes of patient harm, the role of transparency in enhancing safety, and the value of publicly available data in assisting in provider selection. Featured panelists include Dr. Ashish Jha and Dr. Martin Makary.

Improving doctor–patient communication in a digital world.

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Lakshmanan I. The Diane Rehm Show. February 9, 2016.

Digital technologies represent both promise and risks for communication in health care. This radio interview features Dr. Bob Wachter, Dr. Saul Weiner, Cindy Brach, and Dr. Kavita Patel who discuss various influences on effective physician–patient communication, including time pressures, patient portals, electronic documentation demands, and health literacy.

Patient Stories.

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This Web site hosts documentary accounts of medical errors to encourage clinicians to discuss quality and safety issues in health care.

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

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Washington, DC: US Department of Health and Human Services; May 2011.

This training program explores how to create a culture of safety and prevent health care–associated infections.

Hospital-acquired infections.

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This radio program featured interviews with an infectious disease specialist and a patient who contracted a hospital-acquired infection, and discussed how patients and providers can reduce their occurrence.

Obama Administration introduces plan to reduce preventable medical errors.

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This television news interview discusses results of a recent analysis of patient safety improvement efforts, describes the Partnership for Patients program, and offers tips to involve patients in safety.

Postoperative handover: problems, pitfalls, and prevention of error.

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Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-6.

This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.

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