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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 39 Results

Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.
Curated Libraries
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.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Chuck E, Assefa H. NBC News. February 8, 2020.

Maternal morbidity and perinatal harm can be exacerbated due to implicit bias. This story discusses a case of an American Indian/Alaska Native mother and infants whose deaths may have been preventable had her concerns been more effectively addressed. The situation illustrates conditions in the broader indigenous peoples’ community that indicate a lack of respect and patient-centeredness as factors contributing to poor care.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.
CDC; Centers for Disease Control and Prevention.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
Gubar S.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Duffy J, Harris J, Gade L, et al. The Pediatric infectious disease journal. 2014;33:472-6.
Reporting on the investigation into an incident where five pediatric patients died after acquiring a health care–associated infection, this newspaper article describes how delays in diagnosis and treatment along with inadequate communication contributed to patient harm.