The PSNet Collection

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.

Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval.

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Kennerly DA, Kudyakov R, da Graca B, et al. Health Serv Res. 2014;49:1407-1425.

… Tool , this retrospective study analyzed adverse events at a large health care system in Texas. Approximately one-third … safety hazards . A previous AHRQ PSNet interview with Dr. David Classen explored the use of trigger tools to measure …

Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.

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Kennerly DA, Saldaña M, Kudyakov R, et al. J Patient Saf. 2013;9:87-95.

… for Healthcare Improvement's Global Trigger Tool is a widely used approach for detecting and monitoring safety … of the Global Trigger Tool, with the goal of developing a sustainable mechanism for identifying adverse events (AEs), …

Implementing SBAR across a large multihospital health system.

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Compton J, Copeland K, Flanders S, et al. Jt Comm J Qual Patient Saf. 2012;38:261-8.

In this study, implementation of system-wide training and adoption of the structured communication tool SBAR were associated with challenges in uptake and physician education. However, in situations where SBAR was used correctly, physicians were more likely to be able to make clinical decisions.

Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000–2009.

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Harrington L, Kennerly DA, Johnson C. J Healthc Manag. 2011;56:31-43; discussion 43-4.

This review of computerized physician order entry, clinical decision support systems, and bar-coded medication administration discusses the risks created by health care information technology.

Journey to no preventable risk: The Baylor Health Care System patient safety experience.

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Kennerly DA, Richter KM, Good V, et al. Am J Med Qual. 2011;26:43-52.

This commentary describes a process structured around improving safety culture and promoting use of technology to enhance patient safety.

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