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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 29 Results
Perspective on Safety June 1, 2019
… State University of New York at Buffalo Buffalo, NY … Rollin J. Fairbanks, MD, MS … Vice President of Quality and Safety, …
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.
Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26:381-387.
Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.
Patterson D, Higgins S, Lang ES, et al. Prehosp Emerg Care. 2017;21:149-156.
The impact of fatigue on clinician performance is a concern across health care settings. This study explained how researchers developed key questions to help assess fatigue in prehospital emergency medical services. They describe a plan to conduct systematic reviews to inform future guidelines.
Page DB, Donnelly JP, Wang HE. Crit Care Med. 2015;43:1945-1951.
Severe sepsis has been a focus of quality efforts. This retrospective study contrasted community-acquired sepsis with health care–associated sepsis. In line with definitions of health care–associated infections, investigators defined health care–associated severe sepsis as patients hospitalized with severe sepsis with an infection present at admission, where the patient was admitted from an inpatient nursing facility, was on hemodialysis, or was readmitted within 30 days to the same hospital. They separately considered hospital-acquired sepsis cases in which the patients did not have an infection at hospital admission. Both health care–associated and hospital-acquired sepsis, which together accounted for about one-third of cases, had a higher mortality rate and were more severe and costly than community-acquired severe sepsis. This adds to the evidence that health care–associated infections cause significant harm and costs to patients. In a related study, researchers examined readmissions following severe sepsis and found substantial variation in readmission rates, with an overall rate of about 20%, suggesting that targeting sepsis in readmission prevention efforts may be helpful.
Perspective on Safety August 1, 2015
… Georgetown University School of Medicine Washington, DC … Rollin J. (Terry) Fairbanks, MD, MS … Director National … out of his online peer-to-peer community, and how he doesn't like to talk about the fact that he's dying because so many … gibberish because we have this copy-and-paste function. David Blumenthal said to me, "Just because we can copy and …
This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Patterson PD, Weaver MD, Abebe K, et al. Am J Med Qual. 2011;27:139-146.
This study established a consensus definition and rating system for adverse events in emergency medical services (EMS). The guiding principles included a focus on events that were potentially preventable during the continuum of EMS care, and independent of a patient’s clinical progression.