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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 699 Results
Perspective on Safety November 27, 2023

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Healthc Manage Forum. 2023;Epub Aug 30.
The threat of cybersecurity risks to patient safety is receiving increasing attention. This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare system. The guidance addresses key areas of concern (e.g., organizational risk management, technology considerations, contingency planning), provides suggested roles and responsibilities for an organizational cybersecurity team, and emphasizes the importance of cyber incident response planning.
Perspective on Safety August 30, 2023

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Patricia McGaffigan

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Society to Improve Diagnosis in Medicine.
Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The deadline to submit a 2023 nomination is September 12, 2023.
Joint Commission, National Quality Forum.
The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application process. The 2023 award submission cycle is open through August 21, 2023. 

May 31, 2023; Fed Register;88:35694-35728.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.

National Academies of Health.

Delay in access to obstetric care hinders safe treatment for patients experiencing pregnancy complications. This webinar discussed a range of factors affected by abortion restrictions and reviewed options to ensuring safety given legal and other structural impediments. A written brief is forthcoming.
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Rennert L, Howard KA, Walker KB, et al. J Patient Saf. 2023;19:71-78.
High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.
Magnan EM, Tancredi DJ, Xing G, et al. JAMA Netw Open. 2023;6:e2255101.
Rates of prescription opioid misuse and abuse led to recommendations for dose tapering for patients with chronic pain. However, concerns have been raised about the potential harms associated with rapidly decreasing doses or discontinuing opioids. Building on previous research, these researchers used a large claims database to explore the unintended negative consequences of tapering patients on stable, long-term opioid therapy. Findings indicate that opioid tapering was associated with fewer primary care visits, greater numbers of emergency department visits, and reduced adherence to antihypertensive and antidiabetic medications.
Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.
Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram morphine equivalents (MME) up to 3 months following notification as compared to prescribers who are not notified. This article reports on the same cohort’s prescribing behavior at 4-12 months. Among prescribers who received notification, total weekly MME continued to decrease more than the control group during the 4-12 month period.
Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.
This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process is now closed.
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March. 

Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments has passed.
Clark J, Fera T, Fortier CR, et al. Am J Health Syst Pharm. 2022;79:2279-2306.
Drug diversion is a system issue that has the potential to disrupt patient access to safe, reliable medications and result in harm. These guidelines offer a structured approach for organizations to develop and implement drug diversion prevention efforts. The strategies submitted focus on foundational, organizational, and individual prevention actions that target risk points across the medication use process such as storage, prescribing, and waste disposal.