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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 - 18 of 18 Results
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatrics. 2018;142.
This revised set of guidelines suggests standards to ensure high-quality care for pediatric patients in the emergency department, including a section on improving patient safety. Key recommendations focus on pediatric emergency care coordinators and implementing quality control mechanisms.
Frush K, Chamness C, Olson B, et al. Jt Comm J Qual Patient Saf. 2018;44:389-400.
… Joint Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … … a partnership in which a large privately owned group of hospitals, postacute facilities, and outpatient clinics … culture and metrics. The program included an assessment of the quality at each site followed by an individual …
Benjamin L, Frush K, Shaw KN, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:e20162680.

Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures. This guideline provides recommendations for ensuring handoffs are performed in pediatric emergency care and suggests adherence to standard communication methods, coupled with effective training on the use of those tools, can improve the safety of transitions.
Johnson DP, Zimmerman K, Staples B, et al. Hosp Pediatr. 2015;5:154-9.
… Hospital pediatrics … Hosp Pediatr … Handoff improvement is a national … educational intervention for teaching handoffs to pediatric residents did not result in enhanced perception of handoff quality or improvement in clinical outcomes. …
Schwendimann R, Milne J, Frush K, et al. Am J Med Qual. 2013;28:414-21.
American journal of medical quality : the official journal of the American College of Medical Quality … Am J Med Qual … … used for improving safety culture , but their effect on specific patient safety attitudes and outcomes is not well …
Turner K, Frush K, Hueckel RM, et al. J Nurs Care Qual. 2013;28:257-64.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-10.
Reviewing evidence on transitions in care, this article describes how one university health system developed a comprehensive handoff curriculum to address educational needs in the context of changes to resident duty hours.
Gaca AM, Frush DP, Hohenhaus SM, et al. Radiology. 2007;245:236-44.
This study developed a simulation model in the radiology environment and identified the need for greater resuscitation aids to treat unexpected clinical events. A past AHRQ WebM&M commentary discussed the role of simulation as a method to practice both behavioral and technical skills.
Frush K, Hohenhaus S, Luo X, et al. Pediatr Emerg Care. 2006;22:62-70.
The authors distributed an audiovisual education program to inform pediatric emergency care clinicians on the correct use of the Broselow Pediatric Resuscitation Tape. They found that the intervention improved dosing accuracy and administration time.
Perspective on Safety May 1, 2005
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...