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.
Vogus TJ, Ramanujam R, Novikov Z, et al. Med Care. 2020;58:594-600.
… exhibited higher levels of workgroup identification (i.e., the extent to which an individual is psychologically … with higher safety climate perceptions . … Vogus TJ, Ramanujam R, Novikov Z, et al. Adverse events and burnout: …
Ott LK, Pinsky MR, Hoffman LA, et al. BMJ Qual Saf. 2012;21:509-18.
… characterizes the types of emergencies that necessitated a medical emergency team evaluation of an inpatient in the radiology department. A case of an ultimately fatal adverse event that occurred … inpatient unit to radiology is discussed in this AHRQ WebM&M commentary . …
Logio LS, Ramanujam R. Jt Comm J Qual Patient Saf. 2010;36:36-42.
Although resident physicians frequently discussed safety problems informally, they rarely reported such incidents through formal error reporting systems. Low error reporting rates by physicians have been documented in prior studies.
Anderson J, Ramanujam R, Hensel D, et al. Int J Med Inform. 2006;75:809-17.
The authors used a simulation model to analyze organizational response to reported medication errors. They conclude that implementation of voluntary reporting systems must be followed by organizational changes to significantly reduce medication errors.
Thompson DN, Wolf GA, Spear SJ. J Nurs Adm. 2003;33:585-595.
Representatives from University of Pittsburgh Medical Center (UPMC) describe the implementation of the Toyota Production System (TPS), a standardized approach to improving systems mastered at Toyota. Specifically, TPS is a method of managing people engaged in work that emphasizes frequent, rapid problem solving and work redesign. Individuals are expected to identify barriers and problems in the workplace and then are given the responsibility, resources, teaching, and managerial support to correct them by determining the root cause and redesigning work to eliminate recurrence. The authors describe the rationale for applying TPS to health care and its implementation. They provide specific examples in inpatient medication administration and postulate that TPS could significantly improve patient care and safety.