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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 - 13 of 13 Results
Manojlovich M, Frankel RM, Harrod M, et al. BMJ Qual Saf. 2019;28:160-166.
Researchers describe the use of video reflexive ethnography to improve communication between physicians and nurses during rounds at a single academic medical center. They conclude that video reflexive ethnography is feasible and may have the potential to improve communication between physicians and nurses.
Ziring D, Frankel RM, Danoff D, et al. Acad Med. 2018;93:1700-1706.
Unprofessional and disruptive behavior among health care personnel can adversely impact safety, but reporting and addressing such behavior remains challenging. In this mixed-methods study, researchers identify barriers faculty may face when reporting student lapses in professionalism.
Rattray NA, Sico JJ, Cox LAM, et al. Jt Comm J Qual Patient Saf. 2017;43:127-137.
Communication between inpatient clinicians and primary care physicians at the time of hospital discharge is often suboptimal, and it may not have improved with the advent of electronic health records. This qualitative study examined barriers to inpatient–outpatient communication in the care of stroke patients and found that clear communication is needed to ensure effective handoffs.
Bergman AA, Flanagan ME, Ebright PR, et al. BMJ Qual Saf. 2016;25:84-91.
This qualitative analysis found that anticipatory management conversation occurred in most physician-to-physician and nurse-to-nurse verbal handoffs. The authors suggest that structured handoffs should be supplemented with additional verbal communication regarding relevant contextual information.
Flanagan ME, Saleem JJ, Millitello LG, et al. J Am Med Inform Assoc. 2013;20:e59-66.
This ethnographic study used direct observations in 11 primary care clinics with an integrated electronic health record (EHR) to characterize the extent and types of workarounds used by clinicians and support staff. As with prior classic research, the investigators found several different types of paper- and computer-based workarounds, with most being used to aid memory, improve efficiency, or enhance provider awareness of specific clinical problems. For example, several instances of copying and pasting clinical information from note to note were observed, despite this practice being against the institution's policy. Workarounds are generally regarded as representing EHR design failures, but the authors argue that it is unrealistic to expect EHRs to completely obviate the need for paper-based cognitive aids. They advocate for incorporating data on common types of workarounds into human factors–based approaches to improving EHR usability.
Flanagan ME, Patterson ES, Frankel RM, et al. J Am Med Inform Assoc. 2009;16:509-15.
… : JAMIA … J Am Med Inform Assoc … This study found that a patient handoff tool can reliably extract information from … additional opportunities for improvement were identified. A past AHRQ WebM&M commentary discussed a case of a failed signout process …
Kerfoot KM, Rapala K, Ebright PR, et al. J Nurs Adm. 2006;36:582-588.
… Adm … J Nurs Adm … The authors describe the development of a patient safety initiative launched by a three-hospital system, its experience over 5 years, and … of embracing a partnership model. … Kerfoot KM, Rapala K, Ebright P, Rogers SM. The power of collaboration with patient …
Solet DJ, Norvell M, Rutan GH, et al. Acad Med. 2005;80:1094-9.
… Patient Safety Goals for 2006 involves implementation of a standardized approach to handoff communications. This study provides a literature review of patient handoffs and discusses the … responsibility from one person to another." They discuss a broad number of barriers to effective handoffs, such as …