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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 - 6 of 6 Results
Brown A, Cavell G, Dogra N, et al. Int J Med Inform. 2022;164:104780.
Alert fatigue and subsequent overrides are known contributors to preventable adverse events particularly for high-risk drug-drug interactions. Researchers assessed prescribers’ actions following an alert for new prescriptions of Low Molecular Weight Heparins (LMWHs) to patients currently prescribed Direct Acting Anticoagulants (DOACs). More than half of the alerts were overridden but were appropriate and justified in most cases.
Brown A, Dickinson H, Kelaher M. Soc Sci Med. 2018;202:99-107.
Health care leadership can support the success of improvement initiatives. This commentary describes an approach to studying this important relationship through a team development lens. Drawing from the governance and health care literature, the authors suggest a framework to explore teamwork characteristics in executive staff and note gaps in understanding of how personal relationship dynamics and external factors affect board members' work.
Rashed AN, Tomlin S, Aguado V, et al. Int J Clin Pharm. 2016;38:1069-74.
Pediatric medication errors are common. In this study, researchers observed 153 nurse preparations of morphine infusions for pediatric patients and found significant variation in technique, which led to many patients receiving doses higher or lower than what was initially ordered.
Ramsay AIG, Turner S, Cavell G, et al. BMJ Qual Saf. 2014;23:136-46.
Unsafe medication practices and errors occur frequently in hospitals. This study found that ward-level medication safety scorecards were well received by hospital staff but did not result in fewer medication risks.
James L, Davies G, Kinchin I, et al. Adv Health Sci Educ Theory Pract. 2010;15:735-47.
This study found that student and staff pharmacists were both capable of detecting inaccuracies in medication dispensing. However, both groups demonstrated only a superficial understanding of the dispensing process, and were unable to identify underlying system factors that could lead to errors.