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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 - 8 of 8 Results
Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.
Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.
McCoy C, Keshvani N, Warsi M, et al. BMJ Open Qual. 2023;12:e002220.
In-hospital cardiac arrests (IHCAs) are complex clinical scenarios requiring effective communication and teamwork. This study assessed the impact of a bundled, multicomponent intervention to empower telemetry technicians and improve communication between telemetry technicians and other clinicians during in-hospital cardiac arrest. After bundle implementation, researchers observed improvements in IHCA survival.
Salwei ME, Anders S, Slagle JM, et al. J Patient Saf. 2023;19:e38-e45.
Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.
Miller A, Moon B, Anders S, et al. Int J Med Inform. 2015;84:1009-18.
Prior research on whether clinical decision support systems (CDSS) improve patient outcomes has given mixed results. This meta-analysis interpreted qualitative CDSS studies to better understand why these varied results may occur. The authors conclude that knowledge about how to best integrate these systems is largely lacking and further research is needed to address usability, design, and integration of CDSS.
Patterson ES, Doebbeling BN, Fung CH, et al. J Biomed Inform. 2005;38:189-99.
Electronic medical records offer opportunities to generate automatic clinical reminders, a feature believed to improve patient care. This study explored barriers to adoption through several observational and survey techniques. Investigators identified ten barriers to effective use, which included workload, time to remove inapplicable reminders, the use of paper forms, accessibility of workstations, and the presence of resident physician and trainees. Discussion involves detailed account of each barrier and how certain future interventions may address them. The authors advocate using this multiprong methodology to identify barriers to effective use of new information technology.