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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 20 Results
Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jun 24.
Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.
Sachs JD, Karim SSA, Aknin L, et al. Lancet. 2022;400:1224-1280.
COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.
Berman L, Rialon KL, Mueller CM, et al. J Pediatr Surg. 2021;56:833-838.
Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    
Berman L, Ottosen M, Renaud E, et al. J Pediatr Surg. 2019;54:1872-1877.
Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.
Roybal J, Tsao KJ, Rangel S, et al. Pediatr Qual Saf. 2018;3:e108.
Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.
Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.
This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.
Dunn AS, Shetreat-Klein A, Berman J, et al. J Hosp Med. 2015;10:615-8.
A formal hospital discharge transition report for patients taking warfarin was well received by outpatient physicians, but it did not appreciably affect processes of care measures or therapeutic efficacy. A postdischarge medication error involving warfarin was discussed in a previous AHRQ WebM&M commentary.
Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184.
… and executives can act as champions for this work. … Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. … M … N … R … S … Joshi … Erb … Sikka … Zhang … M Joshi … N Erb …
Davis R, Joshi D, Patel K, et al. J Eval Clin Pract. 2013;19:812-8.
This United Kingdom study of safety culture found that medical students showed varying willingness to perform safety-focused behaviors such as asking challenging questions, notifying physicians or nurses of errors, or submitting incidents to the national reporting system.

Jt Comm J Qual Patient Saf. 2012;38(7):289-327.

Highlighting the accomplishments of the 2011 recipients of the John M. Eisenberg Patient Safety and Quality Awards, this issue includes interviews with Kenneth Shine and Jerod Loeb, as well as articles on The Society of Hospital Medicine (Philadelphia, PA); New York-Presbyterian Hospital (New York, NY); and Henry Ford Health System (Detroit, MI).

Jt Comm J Qual Patient Saf. 2009;35(9):583-603.

… 2009;35(9):583-603. … G … C … T … DW … N … S … SR … C … M … B … C … PJ … JM … DJ … JM … Kaplan … Furman … Gandhi … Bates … Zafar … Berman … Watson … George … Martin … Bogan … Goeschel … … … DW Bates … N Zafar … S Berman … SR Watson … C George … M Martin … B Bogan … C Goeschel … PJ Pronovost … JM Maupin … …
Davis K, Schoen S, Schoenbaum SC, et al. New York, NY: The Commonwealth Fund; 2006.
… This report presents findings from a cross-national survey of consumer views of health … Fund; 2006. … The Commonwealth Fund … K … S … SC … AJ … MM … AL … JL … Davis … Schoen … Schoenbaum … Audet … Doty … Holmgren … Kriss … K Davis … S Schoen … SC …
Joshi MS, Hines S. Jt Comm J Qual Patient Saf. 2006;32:179-87.
… low levels of knowledge with respect to quality, a disconnect between CEO perceptions of how well board chairs … performance on quality measures. The authors provide a series of strategic recommendations to close the reported … mechanisms for planning with incentives and maintaining a patient-centered focus. …