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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 - 9 of 9 Results
Sacco AY, Self QR, Worswick EL, et al. J Patient Saf. 2021;17:e1759-e1773.
Using the IOM definition of diagnostic error, this study interviewed hospitalized adults to characterize their experiences with diagnostic errors and their perspectives on causes, impacts and prevention strategies. Nearly 40% of patients interviewed reported at least one diagnostic error in the past 5 years that adversely impacted their emotional and physical well-being. Qualitative analysis revealed five main themes underlying the causes of diagnostic error: problems with clinical evaluation, limited time with clinicians, poor communication between clinicians and patients or between clinicians, and systems failures. Suggested strategies to reduce diagnostic error included improvements to clinical management, increase patient access to clinicians, communication improvements between patients and clinicians and between clinicians, and self-advocacy by patients.
Haller G, Myles PS, Taffé P, et al. BMJ. 2009;339:b3974.
The so-called July phenomenon, in which errors are supposedly more common in July due to an influx of inexperienced residents and students, has long been a source of gallows humor in hospitals. Although prior studies have reached mixed conclusions, this Australian study of anesthesia errors did find a significant increase in preventable adverse events for procedures performed by trainees during the first 4 months of the academic year. Interestingly, error rates were higher for trainees at all levels, not just first-year residents. This finding implies that underlying systems issues as well as clinical inexperience resulted in adverse events. An accompanying editorial calls for revising training models in order to provide adequate supervision and support for new trainees. A case of inadvertent hypoglycemia resulting from an intern's lack of familiarity with insulin ordering at his new hospital is discussed in an AHRQ WebM&M commentary.

Int J Qual Health Care. 2009;21:1-75.  

… … Int J Qual Health Care. 2009;21:1-75.   … Van Der Schaaf T; The World Alliance For Patient Safety Drafting Group; The … … R. … G. … M. … M. … R. … R. … J. … T. … R. … M. … H. … P. … P. … P. … Runciman … Thomson … Castro … Fletcher … Hatlie … Jakob … Koss … Loeb … Perneger … Thomson … Virtanen … Sherman … Hibbert … Lewalle … …
Cleopas A, Villaveces A, Charvet A, et al. Qual Saf Health Care. 2006;15:136-41.
… health care … Qual Saf Health Care … This study presented a medication error scenario to a group of recently discharged patients and discovered that … viewed the error less favorably in association with a slow hospital response, a lack of disclosure, and the …
Pittet D, Simon A, Hugonnet S, et al. Ann Intern Med. 2004;141:1-8.
… directly observed and surveyed more than 160 physicians at a large university hospital to describe current practices and … wide variations across medical specialties. Whereas being a role model, having a positive attitude towards hand hygiene, and easy access to …