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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 - 20 of 35 Results
Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.
Saran AK, Holden NA, Garrison SR. BJGP Open. 2022;6:BJGPO.2022.0001.
Tablet-splitting may introduce patient safety risks, such as unpredictable dosing. This systematic review and qualitative synthesis did not identify substantive evidence to support tablet-splitting concerns, with the exception of sustained-release tablets and use by older adults who may struggle to split tablets due to physical limitations.
Hindmarsh J, Holden K. Int J Med Inform. 2022;163:104777.
Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.
Holden RJ, Carayon P. BMJ Qual Saf. 2021;30:901-910.
Since the SEIPS (Systems Engineering Initiative for Patient Safety) conceptual model was introduced in 2006, several additional versions have been introduced. In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS 101) along with seven simple tools for use by practitioners, researchers, and others.
Holden J, Card AJ. J Patient Saf Risk Manag. 2019;24:166-175.
Negative consequences can radiate throughout an organization after a patient harm event. This commentary provides an overview of first victims, second victims, and third victims of medical errors, then elaborates on how patient safety professionals responsible for investigating adverse incidents and designing improvements can experience emotional stress, bullying, and staff turnover. The authors recommend increased support and measurement of the impact of patient safety events on these individuals.
Holden RJ, Campbell NL, Abebe E, et al. Res Social Adm Pharm. 2020;16:54-61.
This usability study examined whether older adults could use a mobile application to consider the risks and benefits of anticholinergics, a high-risk medication class. The 23 participants reported an overall high usability for the application, suggesting that mobile health information technology has potential to engage patients in safety.
Perspective on Safety April 1, 2018
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
Geneva, Switzerland: World Health Organization; 2016.
Much of patient safety research has focused on the hospital setting, but a majority of health care is delivered in the ambulatory setting. This collection explores key safety topics in the primary care environment: patient engagement, education and training, human factors, administrative errors, diagnostic errors, medication errors, multimorbidity, care transitions, and electronic tools. Each monograph provides an introduction to each area of concern and practical approaches to improvement.
Werner N, Holden RJ. Appl Ergon. 2015;51:244-54.
Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.
Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN: 9780309371544.
Efforts to develop patients' ability to understand health information and follow treatment recommendations can enhance medication safety and engage patients in their care. The Institute of Medicine highlighted health literacy as a safety concern in 2004. This report summarizes the findings of a workshop convened to assess progress in this field and to discuss local, national, and international strategies to advance health literacy improvement.
Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. This workshop report reveals how health literacy affects patients' abilities to follow discharge instructions and makes recommendations to improve after-visit summaries to augment patient understanding of directions.
Garrett SK, Khasawneh MT, eds. Int J Indust Ergon. 2011;41:333-400.
… medication delivery . … Garrett SK, Khasawneh MT, eds. Int J Indust Ergon. 2011;41:333-400. … SK … MT … EK … A. … S. … T. … SE … BS … PR … D. … AM … L. … RJ … RL … SJ … TK … JL … … … Brown … Sui … Holden … Brown … Alper … Scanlon … Patel … Karsh … Grigg … Craig … Patterson … Ebright … Saleem … Bauer …