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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 - 13 of 13 Results
Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.
Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.
Wiegmann DA, Wood LJ, Solomon DB, et al. J Healthc Risk Manag. 2021;41:31-46.
The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based improvements after investigation of patient safety events. The authors provide an overview of the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a decision tool called FACES and describe how these tools can be integrated into the RCA2 framework to foster a comprehensive, human factors analysis of patient safety events and the identification of broader system interventions.
Wood LJ, Wiegmann DA. Int J Qual Health Care. 2020;32:438-444.
… … This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety … factors and more on systems change . The authors propose a multifaceted definition of ‘systems change’ and a rubric … ‘systems change’ (‘systems change hierarchy’). … Wood LJ, Wiegmann DA. Beyond the Corrective Action Hierarchy: a
Pugh CM, Law KE, Cohen ER, et al. Am J Surg. 2020;219:214-220.
… Am J Surg … Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors … and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went …
Carayon P, Hoonakker P, Hundt AS, et al. BMJ Qual Saf. 2020;29:329-340.
… whether integrating human factors engineering into a clinical decision support system can improve the diagnosis … clinical decision support for diagnostic decision-making: a scenario-based simulation study [published online ahead of …
Frasier LL, Quamme SRP, Becker A, et al. JAMA Surg. 2017;152:109-111.
Teamwork training can improve communication and prevention of adverse events in the operating room. In this study, focus groups with clinicians and operating room staff found that team members perceived the concept of the "team" and their roles in ensuring optimal handoff communication differently. This exploratory work has implications for the design of effective teamwork training programs.