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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 1111 Results

Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Publication No. 23-0018.

The AHRQ Surveys on Patient Safety Culture™(SOPS®) Nursing Home Survey assesses safety culture and resident safety in nursing homes. This report summarizes survey data from 3,224 staff working in 62 nursing homes. Respondents reported positive perceptions about both resident safety overall and feedback and communication regarding safety incidents. Areas for improvement included sufficient staffing to handle the workload and maintain resident safety.

Centre for Perioperative Care. London, UK; January 2023.

Patients face risks when undergoing surgery. This revised guidance provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures. The report is centered on areas of effort targeting both organizational and process-level actions. 

Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.
Portland, OR: Oregon Patient Safety Commission.
This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The review of 2021 PSRP data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.

Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures. 
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.

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.

Hare R, Tyler ER, Tapia A, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 22(23)-0008.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The SOPS Workplace Safety Supplemental Item Set for Hospitals was designed for use in conjunction with the AHRQ Hospital Survey to help hospitals assess the extent to which their organization’s culture supports workplace safety for providers and staff. This data analysis found “Protection From Workplace Hazards” as the highest-scoring composite measure and “Addressing Workplace Aggression From Patients or Visitors” as the lowest-scoring composite measure. An average of 34% of healthcare providers and staff experienced symptoms of “Work Stress/Burnout” which represents a 4-percentage point increase from the 2021 pilot study results.
Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-76007-471-5.
Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.

Meyer DB. Boca Raton, FL: Universal Publishers; 2022. ISBN:‎ 9781627344067

Individual commitment to patient safety can motivate change. This book highlights an advocacy action by a patient safety leader to generate awareness, engagement, and action using personal, professional, and patient stories of error.

Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.

Racist behavior directed at either patients or clinicians can degrade the safety of care. This report reviewed over 500 race- or ethnicity-related patient safety incidents to determine the types of actions involved and the role of the individual committing the action. In addition, the impact of the behaviors on the mental health of providers is examined. The report suggests strategies for understanding, detecting, and reducing health disparities.

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.

Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333. 

The care of older adult patients can be complicated due to comorbidities, bias and polypharmacy. This publication reports on a session that examined diagnostic challenges unique to the older adult population. The existing evidence base and strategies for the future are reviewed.

Hare R, Tapia A, Tyler ER, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication No. 22(23)-0066.

Instituting a culture of safety is fundamental to ensuring patient and staff safety. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey is a validated survey that has been widely used to assess patient safety culture since 2004. The 2022 report includes data from 400 hospitals. The highest “percent positive” composite measure scores included both effective teamwork and supervisor, manager, or clinical leader support for suggestions for improving patient safety, and addressing patient safety concerns. Overall, when asked to rate their unit/work area on patient safety, 67 percent of respondents rated their unit/work area as “Excellent” or “Very Good.”

Chicago, IL: The National Association for Healthcare Quality; 2022.

Quality and safety work requires distinct competencies to support effective action and systemic approaches to improvement. This report highlights areas of emphasis and weakness across quality domains and the need for health organization leadership to train and direct designated staff to realize quality and safety goals.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 

Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 21e. New York, NY: McGraw Hill; 2022

The task of performing a safe diagnosis has gone beyond the use of technical skill and knowledge. This book chapter introduces the application of intersecting concepts such as human factors engineering, cognition, information technology, and learning systems to achieve diagnostic improvement.
Newcastle Upon Tyne, UK: Care Quality Commission; October 2022.
This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022 report found most facilities to be generally operating at a effective level and basic performance was found to be high. However the report found substantial gaps in specialties such as maternity care and recognized staffing challenges that impact access and quality.

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.