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Patient Safety Network

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 - 4 of 4 Results
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    • Using smart IV infusion pumps outside of patient rooms.
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    • Messing EG, Abraham RS, Quinn NJ, et al. Am J Nurs. 2022;122.
    When hospitals began to fill up with COVID-19 patients, new strategies had to be developed and implemented quickly to reduce the spread of the virus. This article describes one strategy implemented by a New York hospital: relocating smart intravenous (iv) infusion pumps outside of patient rooms. Challenges, facilitators, and lessons learned are discussed.
    Blame: what does it look like?
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    • Duthie EA. Nurs Manage. 2018;49:18-21.
    … Nursing management … Nurs Manage … A just culture balances organizational context with … difference between blame and accountability as applied to a near miss. The author highlights how accountability enables …
    Application of human error theory in case analysis of wrong procedures.
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    • Duthie EA. J Patient Saf. 2010;6:108-114.
    This study examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the role of human behavior and cognitive processes in the events. The authors conclude that a systems approach is a more effective prevention strategy than relying on education, counseling, and disciplinary action.
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