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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 - 10 of 10 Results
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Abela G. J Tissue Viability. 2021;30:339-345.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Sanner M, Halford C, Vengberg S, et al. J Healthc Risk Manag. 2018;38:47-55.
In this qualitative study at a single university hospital in Sweden, researchers found that hospital middle managers perceived patient safety to be a low priority and that leadership support for patient safety was considered lacking. Underreporting of patient safety incidents and insufficient availability of resources to do patient safety–related work were also cited as significant concerns among the managers interviewed.
Meacock R, Sutton M. Emerg Med J. 2018;35:108-113.
The weekend effect refers to higher rates of adverse outcomes experienced by patients admitted on the weekends. Researchers sought to determine whether adoption of clinical standards for emergency hospital care put forth by the National Health Service in England is associated with the degree to which weekend mortality is increased. Using data from 123 Trusts, they found no association between adoption of these clinical standards and the extent of the weekend effect. This finding suggests that adoption of these standards is unlikely to reduce mortality among patients admitted to the emergency department on the weekend.
Mira JJ, Lorenzo S, Carrillo I, et al. Int J Qual Health Care. 2017;29:450-460.
This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
Applying evidence generated from complaints submitted to health care services has been promoted as a way to inform improvement. This report assesses management of claims against National Health Services trusts to determine the costs involved, ensure appropriate patient compensation, and control incidence of future claims through collaborative care improvement efforts.
Bathla S, Chadwick M, Nevins EJ, et al. J Patient Saf. 2021;17:e503-e508.
Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.