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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 - 19 of 19 Results
Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.
Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.
Turner DA, Bae J, Cheely G, et al. J Gen Intern Care. 2018;10:671-675.
Voluntary reporting of safety events is a widespread patient safety practice, but safety events are known to be underreported, especially by physicians. This uncontrolled intervention study aimed to increase error reporting by residents and fellows by providing a financial incentive of about $200 to report at least two safety events per year. More than half of eligible trainee physicians received the incentive, and the resultant increase in safety reports was sustained over 3 years. One related commentary suggests providing team-based incentives instead of the individual payments, and another commentary questions whether increased safety reporting translates to safer care and urges caution in incentivizing event reporting. A past PSNet perspective discussed the effect of financial incentives on patient safety.
Frush K, Chamness C, Olson B, et al. Jt Comm J Qual Patient Saf. 2018;44:389-400.
… challenge. This quality improvement study describes a partnership in which a large privately owned group of hospitals, postacute … by an individual improvement plan. Each site embarked on a multimodal intervention that included leadership …
Benjamin L, Frush K, Shaw KN, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.
Bhatt M, Johnson DW, Chan J, et al. JAMA Pediatr. 2017;171:957-964.
Procedural sedation is more commonly used among pediatric patients compared to adult patients. In this prospective study across six emergency departments, researchers found that the occurrence of serious adverse events among children receiving sedation varied depending on the type of medication used.
Johnson DP, Zimmerman K, Staples B, et al. Hosp Pediatr. 2015;5:154-9.
… Hospital pediatrics … Hosp Pediatr … Handoff improvement is a national patient safety priority, and residency programs … to provide formal training in signouts. In this study, a simulation-based educational intervention for teaching …
Turner K, Frush K, Hueckel RM, et al. J Nurs Care Qual. 2013;28:257-64.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
Gaca AM, Frush DP, Hohenhaus SM, et al. Radiology. 2007;245:236-44.
This study developed a simulation model in the radiology environment and identified the need for greater resuscitation aids to treat unexpected clinical events. A past AHRQ WebM&M commentary discussed the role of simulation as a method to practice both behavioral and technical skills.
Frush K, Hohenhaus S, Luo X, et al. Pediatr Emerg Care. 2006;22:62-70.
The authors distributed an audiovisual education program to inform pediatric emergency care clinicians on the correct use of the Broselow Pediatric Resuscitation Tape. They found that the intervention improved dosing accuracy and administration time.
Perspective on Safety May 1, 2005
… Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the … world's preeminent academic medical centers. We asked Dr. Karen Frush, a pediatrician who became Duke's Chief Patient Safety …
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...