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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
Gutman CK, Klein EJ, Follmer K, et al. Jt Comm J Qual Patient Saf. 2020;46:573-580.
Use of professional interpreters can reduce language barriers contributing to safety risks, particularly in vulnerable  pediatric populations. This survey of pediatric emergency providers found that despite caring for patients enrolled in a study of professional interpreter modalities, many respondents reported lapses in professional interpretation and commonly reported less frequent and deferred communication due to the need for interpretation.
Brown JC, Tuuri RE, Akhter S, et al. Ann Emerg Med. 2016;67:307-315.e8.
This study describes injuries related to epinephrine autoinjector use by health care workers, patients, or family members when administering epinephrine to treat anaphylaxis. The injuries described in this case series underscore the need to improve medical device design and education for safety, as discussed in a past AHRQ WebM&M perspective.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Garbutt J, Brownstein DR, Klein EJ, et al. Arch Pediatr Adolesc Med. 2007;161:179-85.
Though medical errors are common in pediatric patients, to date few studies have examined pediatricians' attitudes toward errors. This AHRQ-funded study surveyed pediatric residents and attending physicians regarding their experiences with reporting medical errors. The majority of physicians had direct experience with errors and supported disclosing errors to patients and their parents, but only a minority had disclosed a serious error. Respondents expressed dissatisfaction with current means of reporting errors (eg, incident reporting systems) and expressed a desire for formal training in error disclosure. These findings are similar to those previously reported in physicians caring for adult patients.