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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 - 15 of 15 Results
Davies L, Petitti DB, Martin L, et al. Ann Intern Med. 2018;169:36-43.
Overdiagnosis is a growing area of concern within patient safety. The associated overtreatment that results from overdiagnosis can lead to increased financial stress and harm for patients. Although prior research has shown that breast cancer screening may identify lesions that are not clinically meaningful and may lead to unnecessary testing and procedures, explaining the concept of overdiagnosis to patients and providers remains challenging. In this paper, the authors support the United States Preventive Services Task Force cancer screening guidelines and propose a standard definition of overdiagnosis as it relates to cancer screening—the detection of cancer through screening that would not have been otherwise diagnosed in a person's lifetime had screening not taken place. A past PSNet perspective highlighted overuse as a patient safety problem.
Grigg EB, Martin LD, Ross FJ, et al. Anesth Analg. 2017;124:1617-1625.
Medication errors represent a significant source of harm to patients. In this prospective study, researchers created a template to standardize the organization of medications within the anesthesia workspace. Although implementation of the template led to a decrease in anesthesia medication errors, there was no change in errors resulting in patient harm.
Clebone A, Burian BK, Watkins SC, et al. Anesth Analg. 2017;124:900-907.
Checklists have been highlighted as a cognitive aid to avoid omissions in both routine care and critical events. This commentary describes the development and testing of three critical event checklists in children's hospitals and provides implementation guidance to support their use.
Kurth D, Tyler D, Heitmiller ES, et al. Anesth Analg. 2014;119:112-21.
This study describes the early experience of the Wake Up Safe initiative, which is aimed at improving the safety of pediatric anesthesia. The program, which currently includes 19 participating institutions, focuses on identifying adverse events and providing anesthesiologists with quality improvement and safety training.
Tjia I, Rampersad S, Varughese AM, et al. Anesth Analg. 2014;119:122-136.
This commentary provides an overview of root cause analysis methods and describes an initiative that educated its participants in these principles to enhance understanding of serious adverse events reported among collaborating institutions. The authors suggest that utilizing this approach can help proactively inform improvement activities.
Hagerman NS, Varughese AM, Kurth D. Curr Opin Anaesthesiol. 2014;27:323-9.
Cognitive aids have been implemented as decision support tools in complex situations. This review highlights how checklists can help reduce catheter-associated infections, improve reliability of handoffs, and increase adherence to best practices in pediatric anesthesia.
Hudson DW, Holzmueller CG, Pronovost P, et al. Am J Med Qual. 2012;27:201-9.
To detect and analyze errors, health care has traditionally relied on retrospective methods such as incident reporting and root cause analysis. This commentary draws a contrast between this approach and that used in the nuclear power industry, which focuses on prospective error detection through the use of a robust peer-to-peer assessment process. Nuclear power facilities can request peer review by an independent non-regulatory body, which conducts a detailed safety assessment and makes specific recommendations for safety improvement. The authors recommend developing a similar process for hospitals and discuss barriers that would need to be overcome in order to implement such a process.
Pham JC, Gianci S, Battles J, et al. Qual Saf Health Care. 2010;19:446-51.
Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.
Aboumatar HJ, Blackledge CG, Dickson C, et al. Am J Med Qual. 2007;22:232-8.
Morbidity and mortality ("M&M") conferences are standard components of training programs and are mandated by the Accreditation Council for Graduate Medical Education. Despite their ubiquity, a prior study of internal medicine and surgery conferences found that errors were discussed infrequently (particularly in internal medicine); thus, housestaff were being denied an important patient safety learning opportunity. In this study, researchers interviewed conference leaders from 12 departments at an academic hospital and found that only a minority identified patient safety and quality improvement as an important learning objective for the conference. Conferences generally did not include recommended elements for analyzing and learning from errors (e.g., assigning responsibility for follow-up). A prior article described how one residency program redesigned M&M to focus on patient safety and learning from errors.
Makary MA, Holzmueller CG, Sexton B, et al. Jt Comm J Qual Patient Saf. 2006;32:407-410, 357.
The authors describe a postoperative debriefing tool used by surgical teams at Johns Hopkins Hospital and share lessons learned since implementation.
France DJ, Throop P, Walczyk B, et al. J Patient Saf. 2008;1:145-153.
This study evaluated the impact of a newly designed children's hospital on patient safety and job function. The investigators begin with a detailed discussion of the contextual factors involved in their hospital redesign, drawing on human factors approaches in safety interventions. They follow by presenting their hospital design process, sharing both unit and floor layouts aimed to ensure family-centered ideals. Results from the 270 clinical faculty and staff surveys suggested that the majority reported a better overall new facility, more efficient information and patient flow, and high ratings for work environment factors such as lighting and equipment availability. However, providers in intensive care settings expressed concern about the negative impact new designs played in team communications, rates of interruptions, and work processes. As perhaps expected, the findings demonstrated many benefits and some unanticipated consequences of the redesign efforts but ultimately reinforced the need for human factors expertise.