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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 - 7 of 7 Results
Woodcock T, Liberati EG, Dixon-Woods M. BMJ Qual Saf. 2021;30:106-115.
The development of accurate and reliable measurements was identified as a major priority for the patient safety field in an influential 2015 report. This mixed-methods study of a large-scale improvement program in the United Kingdom provides important insights into the challenges of measuring safety in real-world settings. In the program, quality improvement teams at each of the nine participating hospitals chose targets and developed metrics with assistance from external mentors. The measurement strategies were reviewed by the study investigators, who also conducted structured interviews with quality improvement team members at each site. Measurement was a challenge for all sites, attributed in large part to frontline staff's lack of experience in data analysis and reliance on homegrown rather than externally validated safety metrics. This manifested in the use of metrics that often were overambitious, not linked to the interventions that were being implemented, or not analyzed in a statistically appropriate fashion. As a result, it was difficult to determine if improvement in the safety targets had been achieved. A previous PSNet interview featured the study's senior author, Mary Dixon-Woods.
McNicholas C, Lennox L, Woodcock T, et al. BMJ Qual Saf. 2019;28:356-365.
This mixed-methods study used direct observation and interviews to determine whether plan–do–study–act (PDSA) cycles were implemented as planned in a series of quality improvement efforts. The authors found that initial training efforts did not support PDSA implementation and that careful project selection, redesigned training, and hands-on support were all required to support frontline teams in using the PDSA method.
Reed JE, Card AJ. BMJ Qual Saf. 2016;25:147-52.
Rapid-cycle improvement methods have been embraced as an approach to enhancing health care quality and have achieved varying levels of success. This commentary explores how insufficient implementation of plan-do-study-act cycles can hinder its effectiveness as an improvement strategy.
Doyle C, Lennox L, Bell D. BMJ Open. 2013;3.
A classic article that told one patient's tale of the "hospitalization from hell"—an elective admission for an orthopedic procedure that was marked by disorganized, inefficient, and inattentive care—exemplified the need for patient-centeredness as an essential component of high-quality care. Since then, patient satisfaction has become an important quality metric for both hospitals and clinics. This systematic review provides strong evidence supporting the use of patient experiences in this fashion. The authors found a moderately strong correlation between better patient experience and improved patient safety and quality of care metrics across a range of patient populations and health care settings. These findings allay concerns that patient perspectives might focus more on service quality than patient safety and support efforts to improve the patient experience as part of an overall safety improvement strategy.
Vaughan L, McAlister G, Bell D. Clin Med (Lond). 2011;11:322-326.
This survey of physicians about the UK equivalent of the "July effect"—a tradition of nearly 50,000 new doctors starting on the first Wednesday in August—found a high degree of concern for patient care, safety, and training. The authors conclude that there is a need for structural changes.