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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
Card AJ. J Patient Saf. 2023;19:394-395.
A full cycle of examination, planning, and strategic implementation is required to improve safety through system change. This commentary explores reasons for the persistent overemphasis on patient safety incident tabulation and analysis in lieu of the employment of actions that serve to reduce the potential for accident occurrence.
Komashie A, Ward JR, Bashford T, et al. BMJ Open. 2021;11:e037667.
A systems approach is a key element in safe patient care. This systematic review concluded that a systems approach to healthcare design and delivery can lead to significant improvements in patient and service outcomes (e.g., fewer delays for appointments and time-to-treatment).  
Simsekler MCE, Ward JR, Clarkson J. Ergonomics. 2018;61:1046-1064.
In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.
Card AJ. BMJ Qual Saf. 2017;26:671-677.
Investigation of incidents in complex systems can be hindered by time limitations, lack of follow-up, and incomplete resolution. This commentary discusses a commonly used tool to identify root causes of problems. The author highlights its value as a teaching tool but notes that its use for root cause analysis in health care may be misguided as it tends to simplify complex problems and limit understanding of how processes fail.
Reed JE, Card AJ. BMJ Qual Saf. 2016;25:147-52.
Rapid-cycle improvement methods have been embraced as an approach to enhancing health care quality and have achieved varying levels of success. This commentary explores how insufficient implementation of plan-do-study-act cycles can hinder its effectiveness as an improvement strategy.