The PSNet Collection

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.

Covering Health: Patient Safety.

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HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2023.

The role media plays in raising awareness of patient safety issues in a timely and appropriate manner is consequential. This series instructs writers to communicate on medical error and quality topics in a high-quality professional style with discernment of the content being reported. Series contributions include discussions on medical error statistics and outpatient surgery rankings.

Patient Safety/Quality Improvement Primer.

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Otolaryngol Head Neck Surg. 2018-2023.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2023 installment covers measurement.

Ensuring competency and safety when onboarding newly hired professional staff.

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ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.

Psychological safety is required for clinicians to ask questions as they adjust to working in new teams and environments. Part 1 of this article examines the cultural qualities enabling safe onboarding of new practitioners that encourage asking for assistance when uncertainty arises. Recommendations to encourage new hire questioning include mentor programs and scheduled supervisor conversations. Part 2 discusses the role of simulation to build skills in new staff to ensure medication safety.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Pharmacy Education and Practice.

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Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.

Technology, Education and Safety.

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Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Diagnostic Excellence in the ICU: Thinking Critically and Masterfully.

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Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158.

Critical care diagnosis is complicated by factors such as stress, patient acuity and uncertainty. This special issue summarizes individual and process challenges to the safety of diagnosis in critical care. Articles included examine educational approaches, teamwork and rethinking care processes as improvement strategies.

Medical Residents and Burnout

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Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21.

Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This issue covers a range of topics exploring the mental health consequences of residency, factors influencing well-being, and approaches to help individuals successfully navigate the stress of residency.

COVID-19 Content. ISMP Medication Safety Alert!

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March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.

Management of Operating Room Critical Events.

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Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922.

Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on management of, and preparation for, perioperative critical events and rescue should they occur. The authors highlight simulation training, debriefing, and cognitive aids as methods for improving safety in the operating room.

Becoming a High Reliability Organization.

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VHA Forum. Summer 2020;1-12.

High reliability attainment is a stated goal for health care organizations. This special issue covers established initiatives at the United States Veterans Health Administration that draw from high reliability principles to improve care. Topics covered include evaluation priorities, safe patient handling and diagnostic safety.

Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer III Report.

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J Patient Saf. 2020;16:s1-s56.

The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.

Patient Safety.

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Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.

Emerging Concepts in Patient Safety.

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Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.

This publication presents patient safety concepts for anesthesia practice, including decision aids to educate and empower patients about anesthesia choice, environmental hazards, interpersonal communication, team training, and use of technology and simulation as educational tools.

Special Issue on Medication Safety.

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Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15(7):811-906.

Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.

Patient Safety in Obstetrics and Gynecology.

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Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.

Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in this special issue explore various facets of health care quality and safety improvement in the care of women and expectant mothers. Topics covered include the patient experience, safety culture, disparities, program implementation, and the patient's role in safety.

Patient Safety and Quality Improvement.

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Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.

Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology. The reviews highlight systems science, collaboration, leadership models, and patient experience as important to moving safety innovation forward in this specialty.

Quality, Value, and Patient Safety in Orthopedic Surgery.

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Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.

The Second Society for Simulation in Healthcare Research Summit: Beyond Our Boundaries.

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Simul Healthc. 2018;13(3S suppl 1):S1-S55.

Simulation strategies can help examine team interaction and care activities. Articles in this special issue explore the themes presented at an international research symposium on the use of simulation in health care. Topics covered include patient-centered simulation, adaptive learning, and communities of practice.

Teamwork and Teamwork Training in Healthcare.

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Buljac-Samardzic M, Dekker-van Doorn C, Maynard MT. Group & Organization Management. 2018;43.

Teamwork is a core element of care coordination and safety. Articles in this special issue explore current research and activity on teamwork and teamwork training. Topics include organizational support for a team environment, teamwork as a fall-reduction strategy, interdisciplinary team development, and research design.

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