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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 - 11 of 11 Results
Kolla BP, Coombes BJ, Morgenthaler TI, et al. J Gen Intern Med. 2020;36:51-54.
This observational study observed nonsignificant increases in patient safety incidents in the week following the transition into and out of daylight savings time (DST) over an eight-year period. The authors suggest policymakers and health system leadership evaluate risk mitigation strategies such as delayed shift start times during the transition to and from DST.
Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018;93:1571-1580.
Physician burnout is a highly prevalent patient safety concern. Researchers employed data from the American Medical Association to survey United States physicians about burnout and safety. Of 6586 respondents, 54% reported burnout symptoms, consistent with prior studies. More than 10% of respondents reported a major medical error in the prior 3 months, and these rates were even higher among physicians that had symptoms of burnout, even after adjustment for personal and practice factors. The majority of physicians graded their work unit safety as excellent or very good. The authors conclude interventions to improve safety must address both burnout and work unit safety. Because the survey response rate was less than 20%, it is unclear whether these findings reflect practicing US physicians more broadly. An Annual Perspective summarized the relationship between clinician burnout and patient safety.
Wingo MT, Halvorsen AJ, Beckman T, et al. J Hosp Med. 2016;11:169-73.
The volume–outcome relationship—in which increased patient volume is associated with improved outcomes at the individual clinician and hospital level—has been demonstrated in several classic studies of surgical outcomes. However, this analysis of medical admissions to a teaching hospital found indications of an opposite association. Analyzing admissions over a 6-year period, investigators found that a higher total patient census and a greater number of daily admissions were both associated with an increased frequency of safety events (as measured by the AHRQ Patient Safety Indicators). Greater total census and more admissions were both inversely associated with teaching evaluation scores. Taken together, these results imply that increased workload impairs faculty physicians' ability to supervise and teach residents effectively.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;158:515-21.
Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Wittich CM, Burkle CM, Lanier WL. Mayo Clin Proc. 2014;89:1116-25.
Medication safety is an ongoing challenge as adverse drug events continue to contribute to patient harm and death. This review explores medication errors, including common causes, incidence rates, factors that can increase risk, and methods to prevent them.
Cook DA, Hatala R, Brydges R, et al. JAMA. 2011;306:978-88.
Based in part on its success in aviation, simulation technology has emerged as a new method for training health care professionals. While certain settings have demonstrated benefits from simulation training, there is controversy about whether its impact exceeds that of traditional didactic experiences. This systematic review analyzed results from more than 600 studies that evaluated simulation training programs. Overall, there were significant associations between simulation training and improved outcomes of knowledge, skills, and behaviors. Moderate effects on patient-related outcomes were also noted. A past AHRQ WebM&M point–counterpoint discussion debated the benefits of simulation over classroom-based training programs.
Wittich CM, Lopez-Jimenez F, Decker LK, et al. J Gen Intern Med. 2011;26:293-8.
Reflection, or thinking about thinking, is often used as a technique to encourage learning from adverse events. This study describes the development and pilot testing of a case-based system to encourage and measure reflection among faculty physicians at an academic medical center.
Szostek JH, Wieland ML, Loertscher LL, et al. Am J Med. 2010;123:663-668.
… Am. J. Med. … Am J Med … Morbidity and Mortality (M&M) conferences are designed to explore systems that … share examples of using these tools in M&M conferences. … Szostek JH, Wieland ML, Loertscher LL, et al. A systems …