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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 22 Results
Sauro K, Ghali WA, Stelfox HT. BMJ Qual Saf. 2019;29:341-344.
This commentary discusses the challenges associated with detecting and measuring adverse events, the limitations of measurement alone, and the existing methodologies that can be leveraged to improve the accuracy of adverse event detection.
Wiebe N, Varela LO, Niven DJ, et al. J Am Med Inform Assoc. 2019;26:1389-1400.
This systematic review found that while interventions designed to improve inpatient documentation within electronic health records (EHRs) are highly varied, education and EHR reporting systems seem to be more effective in improving electronic documentation for hospitalized patients than other efforts.
Graham AJ, Ocampo W, Southern DA, et al. BMJ Qual Saf. 2019;28:310-316.
… … BMJ Qual Saf … This study examined the implementation of a tool integrated into the electronic health record to export … high sensitivity and specificity when compared to a chart audit and identified a higher proportion of adverse surgical events than …
Forster AJ, Bernard B, Drösler SE, et al. Int J Qual Health Care. 2017;29:548-556.
… time, the World Health Organization ICD-11 will include a taxonomy for quality and safety events . Researchers … safety vignettes gleaned from sources such as AHRQ WebM&M, then they described its strengths and limitations. … detection of errors, adverse events, and near misses on a population level. …
Southern DA, Burnand B, Droesler SE, et al. Med Care. 2017;55:252-260.
… in the accuracy of PSIs, they have been widely employed as a quality metric. The implementation of ICD-10 and diagnosis timing codes necessitate development of a new set of PSIs. This consensus and validation study used a Delphi panel process to determine ICD-10 codes associated …
Okoniewska B, Santana MJ, Holroyd-Leduc J, et al. BMC Health Serv Res. 2016;16:357.
Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.
Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. BMJ Qual Saf. 2016;25:9-13.
… BMJ quality & safety … BMJ Qual Saf … Innovation within a health care system can be hindered when different … and funding. This commentary discusses insights from a health system that, due to restructuring, found various …
Li P, Ali S, Tang C, et al. J Hosp Med. 2013;8:456-63.
Clinical care handoffs occur multiple times every day for each hospitalized patient, and the use of information technology has been advocated as a means of standardizing and improving the quality of handoffs. Although this systematic review identified six controlled studies of computerized handoff tools, it found only limited evidence linking use of such a tool to improved patient outcomes. The available evidence (including a recently published study that was not included in this review) does indicate that computerized handoff tools improve the accuracy and completeness of physician tools, and may improve physician efficiency. A case of a preventable adverse event due to suboptimal handover is discussed in this AHRQ WebM&M commentary.
Li P, Stelfox HT, Ghali WA. Am J Med. 2011;124.
Physicians and patients generally expressed satisfaction with the handoff process when patients were transferred from the intensive care unit to the general ward. However, direct verbal communication occurred in only a small minority of cases, and several preventable errors did occur, implying the need for a more standardized process.
Drösler SE, Klazinga NS, Romano PS, et al. Int J Qual Health Care. 2009;21:272-8.
This study applied the AHRQ patient safety indicators (PSIs) to acute care hospitals internationally and discovered that certain indicators (e.g., birth trauma and complications of anesthesia) may be unreliable for comparison. However, the authors suggest that publishing comparable international data is feasible after addressing the global challenges with data reliability and quality. The latter is complicated by suspected variations in coding and clinical documentation that require further investigation.