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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 - 12 of 12 Results
Ruppel H, Dougherty M, Bonafide CP, et al. BMJ Open Qual. 2023;12:e002342.
Alarm fatigue can lead to desensitization to safety alerts and threaten patient safety. In this survey of 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation where an alarm went unchecked despite a patient requiring urgent attention. The researchers found that alarm burden was more common among respondents who rated their hospital’s safety as poor or reported poor work environments.
Cicero MX, Baird J, Brown L, et al. Prehosp Emerg Care. 2023;Epub Sep 12.
The pediatric population faces unique challenges in the prehospital setting. This prospective chart review study classified adverse safety events (ASE) of pediatric patients at 15 emergency medical services (EMS) agencies. More than 20% of encounters contained at least one ASE, although most were unlikely to cause harm (e.g., missed documentation).
McLoone M, McNamara M, Jennings MA, et al. J Hosp Med. 2023;18:994-998.
Healthcare workers can become desensitized to electronic safety alerts (alert fatigue) which can lead to errors and adverse events. Based on Safety II concepts such as organizational resilience and using in situ simulations of critical hypoxemic-event alarms in pediatric inpatient settings, this study identified four types of system resilience contributing to alarm resilience – secondary notification, team-based care, direct visualization of bedside monitors from outside patient rooms (or a central monitoring station) and presence at the bedside.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. J Allergy Clin Immunol Pract. 2020;8:1239-1246.e3.
This simulation study involved 28 hospitals in 6 countries to characterize medication errors involving epinephrine administration for pediatric anaphylaxis. The study found that medication administration errors were common and identified latent safety threats (including related to the use of cognitive aids) at several institutions.
Wong AH, Auerbach MA, Ruppel H, et al. Simul Healthc. 2018;13:154-162.
… … Simul Healthc … Workplace violence in health care is a particular area of concern in the emergency department (ED). Patients who are agitated present a unique management challenge for ED providers because they … This mixed-methods study concludes that simulation may be a helpful tool for improving teamwork when caring for …
Lord K, Parwani V, Ulrich A, et al. Am J Emerg Med. 2018;36:1246-1248.
Overcrowding in the emergency department (ED) may adversely impact patient safety. Less is known about the relationship between extended boarding time in the ED and patient outcomes. This observational study found that patients boarding for more than 4 hours in the ED did not experience worse outcomes in the first 24 hours of admission compared to patients transferred out of the ED to an inpatient service in under 4 hours.
Hayden EM, Wong AH, Ackerman J, et al. Acad Emerg Med. 2018;25:221-229.
Human factors engineering is an approach to improve safety of care processes. This commentary provides an overview of human factors research in health care and barriers to its use. The authors discuss how applying human factors using simulation can improve emergency medicine and spotlight the importance of demonstrating its impact on outcomes.