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.
Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.
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. 2020.
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.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.