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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 - 18 of 18 Results
Patterson D, Higgins S, Lang ES, et al. Prehosp Emerg Care. 2017;21:149-156.
The impact of fatigue on clinician performance is a concern across health care settings. This study explained how researchers developed key questions to help assess fatigue in prehospital emergency medical services. They describe a plan to conduct systematic reviews to inform future guidelines.
Boyle TA, Bishop A, Morrison B, et al. Res Social Adm Pharm. 2016;12:772-83.
High-quality error investigation can pave the way for safety improvement. This survey of community pharmacists found that a blame-free culture promotes learning from error investigation, but work stress impedes safety culture. The authors suggest that working conditions and safety culture should be addressed in order to improve safety in community pharmacies.
Lang A, Toon L, Cohen SR, et al. Safety Health. 2015;1:3.
This qualitative study of palliative care recipients, family caregivers, and paid home health staff found that they conceive of safety as encompassing emotional as well as functional safety, and they accept some risk in order to remain in the home environment. This work emphasizes the need for setting-specific patient engagement to tailor safety efforts.
Zed PJ, Black KJL, Fitzpatrick EA, et al. Pediatrics. 2015;135:435-43.
Prior research has found that adverse drug events are a common source of emergency department (ED) visits and hospital admissions in adults. This prospective observational study involved more than 2000 pediatric patients presenting to an ED at a tertiary academic medical center in Canada. Medications were directly related to the presenting chief complaint in 8% of patients, with two-thirds of these deemed preventable. The vast majority of medication-related visits were classified as causing moderate harm, but approximately 5% of cases were severe. Children with a medication-related ED visit were much more likely to be admitted to the hospital and to have a longer length of stay than children presenting to the ED with other problems. The results of this study add to a prior systematic review by the same research group, which also found that a significant proportion of adverse drug events in pediatric patients presenting to the ED were likely avoidable.
Macdonald M, Heilemann MS, MacKinnon NJ, et al. Qual Health Res. 2014;24:536-50.
This qualitative study characterized inpatients' roles in taking medications from both the patient and nursing perspectives. Researchers found significant barriers to engaging patients in medication administration including inpatients' mental status and nurses' time limitations. Previous recommendations to engage patients in their own care have not addressed these factors.
Blais R, Sears NA, Doran D, et al. BMJ Qual Saf. 2013;22:989-997.
Adverse events are thought to be common in patients receiving home health care, but few high-quality studies address this issue. This prospective cohort study found that 1 in 10 home care patients experienced an adverse event each year, and more than half of these events were considered preventable.
Hartnell N, MacKinnon NJ, Sketris I, et al. BMJ Qual Saf. 2012;21:361-8.
Underutilization of voluntary error reporting systems can result in a skewed picture of patient safety. This focus group study explored reasons why pharmacists, nurses, and physicians do not voluntarily report medication errors and identified specific barriers to error reporting.