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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 52 Results
WebM&M Case February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

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...

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2021.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
WebM&M Case November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

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.   

Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.
 

The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Patient Safety Primer September 7, 2019
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
Davis SS, Babidge WJ, McCulloch GAJ, et al. ANZ J Surg. 2019;89:764-768.
Clinical decision-making is a complex process affected by many factors and has important implications for patient outcomes. Using data from the Australian and New Zealand Audit of Surgical Mortality database over a 1-year period, researchers fully audited 3422 deaths and identified 226 cases involving a clinical decision-making incident (CDMI) thought to be concerning by reviewers. The most frequently noted incident was decision to operate, followed by diagnostic error and insufficient postoperative evaluation. The authors suggest that thorough discussion of complex cases in advance of surgery might mitigate CDMIs related to decisions to perform surgery and that retrospectively reviewing deaths for such CDMIs may supplement existing processes for reviewing and learning from surgical mortality. A WebM&M commentary discussed an incident involving a diagnostic error in which a patient was taken to the operating room for an unnecessary surgery.
Graber ML, Berg D, Jerde W, et al. Diagnosis (Berl). 2018;5:257-266.
This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Broman KK, Gaskill CE, Faqih A, et al. JAMA Surg. 2019;154:117-124.
This prospective study examined the impact of wound photography on surgeons' remote diagnosis and suggestions for management of surgical site infections (SSIs). When wound photographs were provided along with clinical scenarios, researchers found no change in diagnostic accuracy, a decrease in sensitivity, and an increase in specificity. The inclusion of images led to changes in surgeons' assessments in 27% of cases, both from correct to incorrect and incorrect to correct in almost equal numbers. Surgeons did report improved confidence in diagnosis of SSIs when photographs were included, whether or not their assessment was correct.
WebM&M Case August 1, 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA.

Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.
WebM&M Case November 1, 2016
After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.
Perspective on Safety June 1, 2015
Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.
St Paul, MN: Minnesota Department of Health; 2015.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.