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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 - 10 of 10 Results
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Plews-Ogan M, May NB, Owens J, et al. Academic Medicine. 2015;91.
This interview study with second victims—physicians who had made a serious medical error—found that although the majority disclosed the error to patient or family, less than 10% had received disclosure training. Disclosure and apology, forgiveness, and preventing recurrence helped physicians cope with medical errors.
Perspective on Safety August 22, 2014
… by suggesting that inpatient errors are more important—i.e., more serious, more common, or more costly. Current … errors that have potential for patient injury is 3%, that's about 108,000 potentially harmful prescription errors per … Intern Med. 2003;138:161-167. [go to PubMed] 6. Woods DM, Thomas EJ, Holl JL, Weiss KB, Brennan TA. Ambulatory care …
This piece describes the new landscape of patient safety in outpatient care, including elements adapted from hospital settings and the growing evidence base for ambulatory-specific efforts.
Dr. Sarkar is an associate professor of medicine at UCSF whose research has focused on ambulatory patient safety, including missed and delayed diagnosis, adverse drug events, and monitoring failures for outpatients with chronic diseases. We spoke with her about patient safety in the ambulatory setting.
Plews-Ogan M, Owens JE, May NB. Patient Educ Couns. 2013;91:236-42.
Clinicians who commit a medical error experience a wide range of emotional responses, including loss of confidence in their job performance, job dissatisfaction, and even overt depression and burnout. This qualitative study used in-depth interviews to explore the coping strategies that physicians used to deal with these emotions. Physicians experienced fundamental changes in both personal and professional relationships, describing themselves as having increased compassion, humility, and tolerance for uncertainty as a result of being involved in an error. Interestingly, few reported utilizing institutional resources to help with the recovery process, instead relying on informal support from colleagues. This study illustrates the second victim phenomenon that affects many clinicians who are involved in medical errors, which is explored in more detail in an AHRQ WebM&M interview.
Voss JD, May NB, Schorling JB, et al. Acad Med. 2008;83:1080-7.
Despite increased focus on safety and quality in health care, prior studies have documented that residency programs miss opportunities to engage trainees in learning about patient safety. This study describes the successful implementation of a longitudinal curriculum in patient safety and quality improvement for internal medicine residents, centered around root cause analysis of adverse events.