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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 - 20 of 21 Results
Longo BA, Schmaltz SP, Williams SC, et al. Jt Comm J Qual Patient Saf. 2023;49:511-520.
Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.
Baker DW, Campbell R. Jt Comm J Qual Patient Saf. 2019;45:589-590.
Testing process improvements prior to implementation can help identify and address potential unintended consequences on practice. This commentary explores how a quality improvement initiative seeking to reduce the opportunity for mistakes may have resulted in treatment delays.
Williams SC, Schmaltz SP, Castro GM, et al. Jt Comm J Qual Patient Saf. 2018;44:643-650.
… Saf … The Joint Commission identifies inpatient suicide as a sentinel event . Little is known about the epidemiology of … suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies …
Perspective on Safety February 1, 2017
… team training in health care. TeamSTEPPS was the result of a multi-year research and development project jointly funded … of teamwork, team training, and patient safety. … David P. Baker, PhD … Executive Vice President Center for Research, …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.
Chassin MR, Baker DW. JAMA. 2015;313:1795-6.
Professionalism in medicine is considered an essential component of safety culture, but efforts to monitor and address disruptive behaviors among physicians have not produced the desired outcomes. This commentary discusses the need for more explicit emphasis on building physician skills and attitudes to support zero harm, process improvement, high reliability, and commitment to excellence in all areas of medical care.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-9.
Failure to adequately follow up on test results is a known problem after hospital discharge, in primary care settings, and within computerized systems. This study reviewed more than 5400 patient medical records from 19 community-based and 4 academic primary care practices and discovered a 7.1% rate of failure to inform (or document informing). Interestingly, investigators found that partial electronic health records (EHRs), with a mix of paper and electronic systems, were associated with higher failure rates than those practices without an EHR or with a complete EHR. Variations in failure rates among practices, ranging from 0% to 26%, suggest that best practices can make a significant difference. A past AHRQ WebM&M commentary discussed the impact of delayed notification for a test result following hospital discharge.
Baker DW, Wolf MS, Feinglass J, et al. Arch Intern Med. 2007;167:1503-9.
This prospective cohort study found increased mortality among elderly persons with poor health literacy, even after adjusting for confounding factors. Poor health literacy has previously been linked to inability to understand prescription drug labels.
Kripalani S, LeFevre F, Phillips CO, et al. JAMA. 2007;297:831-841.
Patients discharged from the hospital experience an unacceptably high rate of medical errors. Prior research suggests that suboptimal communication between hospital physicians and outpatient physicians could contribute to these problems. This study systematically reviewed the literature to determine the frequency of communication problems between physicians at hospital discharge and to identify interventions that ameliorated this problem. The investigators found that direct communication occurred rarely, and the primary means of communication (the dictated discharge summary) generally was not available in a timely fashion and often contained inadequate information for proper follow-up care. Based on this review, the authors provide suggestions for standardizing information transfer at discharge and improving the timeliness of communication.
Davis TC, Wolf MS, Bass PF, et al. Ann Intern Med. 2006;145:887-94.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. In this study, researchers surveyed patients in three urban primary care clinics serving predominantly indigent populations, and found that low health literacy was independently associated with misunderstanding of prescription drug label instructions. Although the study did not directly evaluate if misunderstanding led to medication errors, the study adds to a growing body of research documenting that patients with low and marginal health literacy have difficulty comprehending prescribing information. In the accompanying editorial, Dr. Dean Schillinger calls for development of standardized systems for transmitting medication instructions to patients in a clear and understandable fashion.
Alonso A, Baker DP, Holtzman A, et al. Human Resource Management Review. 2006;16.
This article describes the development of the US Department of Defense's team training program for military health facilities, entitled TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). The program was based on two prior military crew resource management (CRM) programs and prior evidence in the field and was adapted to address issues encountered in military facilities, including the rapid turnover of personnel and the need to adapt to the cultures of specific military services. The program consists of teaching core skills in leadership, situation monitoring, team support, and communication through an interactive curriculum stressing application to everyday scenarios. The article extensively reviews the challenges of implementing the program and future plans for disseminating and evaluating the training.
Davis TC, Wolf MS, Bass PF, et al. J Gen Intern Med. 2006;21:847-51.
This study addresses the relationship between low health literacy and comprehension of common prescription drug warning labels. Patients at an urban primary care clinic underwent structured interviews to address their understanding of specific one-step warnings (ie, take with food) and multi-step warnings (ie, avoid prolonged exposure to sunlight while taking this medication). The majority of the study population had low or marginal health literacy, defined as reading at an 8th grade level or lower. Patients with low literacy were significantly less likely to correctly interpret warning labels, and multi-step instructions were misinterpreted by the majority of respondents across all literacy levels. Misinterpretation of these common warnings could conceivably lead to misuse of medications or adverse drug events.
Pronovost P, Holzmueller CG, Needham DM, et al. Crit Care Med. 2006;34:1988-95.
… is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how … know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to …
Yap C, Dunham D, Thompson JA, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;31.
The investigators analyzed electronic records and found that dosing errors were common in ambulatory care settings for patients with renal insufficiency. They conclude that computerized decision support systems should be implemented in ambulatory care.