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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 - 12 of 12 Results
Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

Kathleen Sanford

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

Perspective on Safety March 15, 2023

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

Dr. Neal Sikka and Dr. Colton Hood are emergency medicine physicians who work in the Innovative Practice & Telemedicine section at George Washington University Hospital (GW). We spoke with them about their experience implementing remote patient monitoring (RPM) programs, GW’s Maritime Medical Access program, and patient safety considerations in the remote environment.

Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Michelle Schreiber photograph

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Perspective on Safety September 28, 2022

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

Freya Spielberg

Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC. Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.

Perspective on Safety September 28, 2022

Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC.

Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC.

Patient Safety Primer February 24, 2022
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated
Kannampallil TG, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30:755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.  
Maloney LM, Alptunaer T, Coleman G, et al. J Emerg Med. 2020;59:872-883.
Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).
Backman C, Cho-Young D. Patient Prefer Adherence. 2019;13:617-626.
Hospital discharge is a complex process that requires patient and caregiver engagement in order to transpire safely. Interviews with members of a Canadian patient safety organization who had recently been discharged from the hospital revealed that they desired better communication as well as more attention to their social determinants of health. A PSNet perspective discussed interventions to improve safety during the transition from hospital to home.
Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.