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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 - 6 of 6 Results
Raff L, Moore C, Raff E. Hosp Pract (1995). 2023;51:29-34.
Language barriers can lead to diminished care and threaten patient safety. This retrospective study included patients with rapid response team (RRT) activation and compared disease severity and outcomes for patients whose primary language was Spanish versus English. Findings suggest that language barriers may contribute to delays in RRT activation and delays in care.
Moore C, Saigh O, Trikha A, et al. J Patient Saf. 2008;4:241-244.
Physicians reported dissatisfaction with their ability to follow up on test results in a timely fashion, with resident physicians frequently reporting an inability to check test results in less than 1 week. The need for standardized methods for following up test results in ambulatory care was noted in a prior study.
Moore C, McGinn T, Halm E. Arch Intern Med. 2007;167:1305-11.
Hospitalized patients are frequently discharged with test results or diagnostic workups pending, with the intention that these will be followed up by outpatient physicians. However, a recent systematic review found that communication between inpatient and outpatient physicians is suboptimal, with primary care physicians frequently being unaware of patients' discharge needs. This study reviewed discharges from the medical service at an academic hospital to determine how often outpatient workups were recommended and completed. More than one-third of recommended outpatient investigations were not completed, frequently because the discharge summary did not contain details of the necessary workup, or because the discharge summary was not available at the time of the patient's clinic visit. Recognition of this problem has led to the development of formal discharge checklists to ensure optimal communication at the time of hospital discharge.
Lin JJ, Dunn A, Moore C. Am J Med Qual. 2006;21:178-84.
This study discovered that nearly 75% of internal medicine residents reported difficulty in following up on test results, with almost one-half citing that the patient's condition deteriorated due to these delays. The authors describe the most commonly reported barriers to timely follow-up (eg, lack of a reminder system, too many competing demands) and discuss the need to address these system deficiencies.