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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 - 10 of 10 Results
Clapper TC, Ching K. Med Educ. 2020;54:74-81.
Optimizing communication during handoffs in the operating room and many other contexts within health care is key to maintaining patient safety. Although prior research has shown that communication breakdowns frequently contribute to adverse events, the degree to which medical errors can be attributed to communication failures as the primary cause remains unknown. In this systematic review, researchers found three dominant categories of medical error: errors of commission, errors of omission, and errors resulting from communication deficiencies. Of the 42 articles that met inclusion criteria, errors of communication were common in 3 studies. They conclude that medical errors more often result from errors of commission or omission rather than miscommunication. A past WebM&M commentary described an incident involving miscommunication in the operating room that led to an error in patient care.
Clapper TC, Ng GM. Clin Simul Nurs. 2012;9.
This commentary explores barriers to implementing TeamSTEPPS, such as limited resources, inadequate training, and poor understanding of the effect of hierarchy on safety, and recommends tactics to address them.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.
Yates GR, Hochman RF, Sayles SM, et al. Jt Comm J Qual Patient Saf. 2004;30:534-542.
This hospital received national recognition for their incentive programs and leadership engagement, and for successfully balancing a culture that supports a "just" approach to error without avoiding accountability. The application of Red Rules, a stop-the-line philosophy, and simplification of administrative barriers helped them achieve an environment that supports safety and learning.