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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 - 16 of 16 Results
Pool N, Hebdon M, de Groot E, et al. Front in Public Health. 2023;11:1014773.
Clinical decision-making can be influenced by both individual and team factors. This article describes the de Groot Critically Reflective Diagnoses Protocol (DCRDP), which can be used to evaluate how group dynamics and interactions can influence collective clinical decision-making. Transcripts of recorded decision-making meetings can be coded based on six DCRPD criteria (challenging groupthink, critical opinion-sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation), which identify teams that are interactive, reflective, higher functioning, and more equitable.
Dharamsi A, Hayman K, Yi S, et al. J Hosp Infect. 2020;105:604-607.
This article describes the use of a rapid-cycle in-situ simulation (ISS) program to facilitate identification and resolution of organizational and systems-level safety threats (i.e., latent safety threats) involving a possible COVID-19 case. Identified threats fell in four domains: personnel, personal protective equipment, supply/environment, and communication. Most participants felt better prepared to provide care after the ISS training.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Ruedinger E, Olson M, Yee J, et al. Am J Med Qual. 2017;32:625-631.
Diagnostic error has yet to be formally integrated into graduate medical education. This commentary describes the design, implementation, and evaluation of a resident curriculum on diagnostic errors that explored medical decision making, critical thinking skills, and how to provide feedback and support for second victims.
Ning H-C, Lin C-N, Chiu DT-Y, et al. PLoS One. 2016;11:e0160821.
Correct identification of patient specimens is crucial to timely and accurate diagnosis. This pre–post study demonstrated substantial improvements in already low rates of patient specimen identification errors following each of three successive strategies: discarding improperly labeled specimens, using barcodes, and automating specimen labeling.
Needleman J, Pearson ML, Upenieks V, et al. Jt Comm J Qual Patient Saf. 2016;42:61-69.
This evaluation of the Transforming Care at the Bedside initiative—a collaborative intended to drive engagement of bedside nurses in enhancing safety through unit-based quality improvement projects—found highly positive perceptions of the program and evidence of widespread implementation of new innovations.

Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18.

Articles in this special issue discuss the impact of resident duty hours (such as how they can affect education, resident well-being, and patient outcomes), explore challenges associated with addressing resident fatigue, and describe strategies for hospitals to adapt to changing work hour requirements.
Evans AS, Yee M-S, Hogue CW. Anesth Analg. 2014;118:687-9.
Most studies examine handoffs from the operating room (OR) to the intensive care unit (ICU). However, this review identified potential safety concerns during transitions in the opposite direction—from ICU to OR—to highlight risks related to coordinating these patient transfers. The authors include a checklist to enhance the safety of such transitions.
Khoo AL, Teng M, Lim BP, et al. Jt Comm J Qual Patient Saf. 2013;39:205-212.
This study involved nurses, physicians, and pharmacists in a collaborative process to design and implement a high-alert medication list at six Singaporean hospitals. Multiple interventions were implemented to improve safety of these medications, resulting in a significant reduction in adverse drug events.
Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3.
This report analyzes communication practices between emergency and primary care physicians and provides suggestions to improve and encourage meaningful communication.

Health Aff (Millwood). 2010;29(9):1564-1619.

… Chandra … Gawande … Studdert … Thomas … Ziller … Thayer … Carrier … Reschovsky … Mayrell … Katz … Semel … Resch … … … DM Studdert … JW Thomas … EC Ziller … DA Thayer … ER Carrier … JD Reschovsky … RC Mayrell … D. Katz … ME Semel … …

Am J Nurs. 2009;109(suppl 11):3-80, C3.  

… 11):3-80, C3.   … K. … LB … HU … PH … J. … ML … VV … LM … T. … D. … M. … L. … V. … L. … PA … CQ … M. … J. … C. … JL … PD … E. … MF … TJ … JR … WM … WM … L. … NJ … K. … C. … H. … S. … … … Parkerton … Needleman … Pearson … Upenieks … Soban … Yee … Struth … Laskow … Newman … Henderson … Henderson … …
Briant R, Morton J, Lay-Yee R, et al. N Z Med J. 2005;118:U1591.
The authors analyzed surgical adverse events to assess the occurrence, cause, patient impact, and preventability of the incidents. They found that the surgical events increased average lengths of stay by 9.9 days and have a lower level of preventability than other types of adverse events.