Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 23 Results
Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.
Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.
Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2021;17:e335-e342.
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
McDonald KM, Su G, Lisker S, et al. Implement Sci. 2017;12:79.
Diagnostic error in the ambulatory care setting is common, particularly with regard to missed or delayed diagnoses of cancer. This study used human factors engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor patients with high-risk conditions and to identify vulnerabilities in the monitoring process that could lead to delayed diagnoses.
Patterson ES, Sillars DM, Staggers N, et al. Jt Comm J Qual Patient Saf. 2017;43:375-385.
Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.
Hefner JL, Hilligoss B, Knupp A, et al. Am J Med Qual. 2017;32:384-390.
… Quality … Am J Med Qual … Crew resource management (CRM), a type of team training , is a prime example of an aviation strategy often applied to … three hospitals. After the training, investigators found a significant, consistent improvement across multiple domains …
Hilligoss B, Vogus TJ. Medical Care Research and Review. 2014;72.
This ethnographic study explored the underlying reasons for safety and communication problems at the transition of care between the emergency department and hospital wards. Through observation and interviews with physicians and hospital leadership, the study identifies structural and cultural barriers to effective communication and reveals time-consuming workarounds that physicians utilized to ensure patient safety.
Hilligoss B, Mansfield JA, Patterson ES, et al. Jt Comm J Qual Patient Saf. 2015;41:134-143.
Handoffs transfer accountability for a patient from one clinician to another. This commentary proposes a framework for transfers from the emergency department to other units within the hospital that highlights environmental, organizational, and social factors that affect these interactions to augment handover quality.
Hilligoss B, Moffatt-Bruce SD. BMJ Qual Saf. 2014;23:528-33.
Communication failures at the time of patient handoffs have been frequently implicated in adverse events. Comparing how narrative modes of communication such as storytelling and structured tools like checklists can be utilized to augment information transfers in health care, this commentary advocates for more research into strategies to improve narrative thinking.
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. BMJ Qual Saf. 2014;23:483-9.
Researchers performed direct observation of nurse and physician handoff communication to assess their use of interactive questioning, a recommended aspect of this approach. Experienced providers utilized more interactive questioning, and physicians used interactive questioning more often than nurses. These results suggest that providers acquire handoff skills over time and that such techniques may be needed in education for less experienced providers.
Patterson ES, Wears RL. Jt Comm J Qual Patient Saf. 2010;36:52-61.
… the seven primary functions of handoffs with each tied to a set of different interventions for improvement. The … the lack of consensus about the primary purpose of a handoff, and that the definition should avoid an overly … challenges in developing handoff improvement strategies. A past AHRQ WebM&M commentary discussed a case of a handoff …
Cheung DS, Kelly JJ, Beach C, et al. Ann Emerg Med. 2010;55:171-80.
Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.
Flanagan ME, Patterson ES, Frankel RM, et al. J Am Med Inform Assoc. 2009;16:509-15.
… : JAMIA … J Am Med Inform Assoc … This study found that a patient handoff tool can reliably extract information from … additional opportunities for improvement were identified. A past AHRQ WebM&M commentary discussed a case of a failed signout process that contributed to a
WebM&M Case November 1, 2008
… coordination: Reduce, Reveal, Focus. … The Case … A 3-month-old infant was admitted with a respiratory … 45 minutes later, the unit clerk called the infant's bedside nurse to report that the infant's parents believed … heuristics suggest productive directions to explore. … Emily S. Patterson, PhD … Research Scientist Institute for …