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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 - 20 of 47 Results
Curated Libraries
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.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

Collaborative for Accountability and ImprovementApril 26, 2022.

Communication and resolution programs (CRP) can improve response to patients and families after a harmful medical error. This session examined how silos negatively impact transparency after error and how CRPs can reduce siloed communication. The session features Dr. Jo Shapiro as a panelist.

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.

Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.

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. 

Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.   

Skin of Color Society Foundation, NEJM Group, and VisualDx. October 28--December 2, 2020.

Diagnostic decision making can be affected by implicit racial bias. This 4-part series explored tools and techniques to improve diagnosis in patients of color. Topics covered included structural racism, explicit analysis of disease patterns and treatments, cultural competency, and policy improvement.   

Shaprio J. National Public Radio. April 15, 2020.

Access to care has been strained by the COVID-19 pandemic. This radio segment discusses how implicit biases can affect care of patients with disabilities. It highlights how preconceptions about this patient population could limit their access to treatments should they become ill.
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.
Oakbrook Terrace, IL: Joint Commission: October 2019.
Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in the patient’s care and the other that shares strategies to prevent the event from occurring. 
The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019.
Misdiagnosis growing area of concern in health care. This radio feature explores three commonly misdiagnosed conditions to share areas of weakness and improvement opportunities. The piece recommends actions for patients and physicians to enhance diagnostic accuracy that include enhancing teamwork, data analysis and encouraging patients to ask questions.
Agency for Healthcare Research and Quality. October 30, 2019.
This webinar recording provides information on the updated Hospital Survey on Patient Safety Culture™ (SOPS™) 2.0. The hospital survey was revised and pilot tested after incorporating user feedback. The Hospital SOPS survey, which has been used by hundreds of hospitals in the U.S. and overseas, allows healthcare providers and staff to assess a hospital’s patient safety culture. Speakers at the webinar discussed what’s different and what to expect when transitioning to the revised survey. Access the SOPS Hospital Survey 2.0, including a user’s guide, as well as results from a 2019 Pilot Test of Version 2.0 and frequently asked questions.
Kliff S, Pinkerton B, Weinberger J, Drozdowska A. Vox. October 23, 2017.
This audio segment discusses two incidents involving pediatric patient harm associated with central line use and highlights successful reduction of central line infections after investigation, standardization, and checklist use in many hospitals.
Lantz F; WBUR.
Partnerships between physicians and patients can yield important outcomes that support safety improvements. This radio segment reports insights from both the patient and clinician involved in an adverse event and how this incident launched an organization that focuses on support for patients and clinicians that have been affected by medical errors.

Medscape. 2016–2017.

Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection highlights particular clinical areas of concern such as neurology and infectious disease. The articles offer expert commentary and review strategies to avoid common reasoning errors.
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.
Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014.
Patient stories are a growing component of understanding the impact of medical errors on patients and uncovering underlying causes. This video features an in-depth interview with the father of an infant who died following delayed diagnosis and treatment for sepsis. The father's quest to understand what happened led to a comprehensive inquiry that revealed regulatory failures and systemic issues with transparency.