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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 - 20 of 26 Results
Davidson JE, Doran N, Petty A, et al. Am J Crit Care. 2021;30:365-374.
The Joint Commission implemented medication management titration standards in 2017, with revisions in 2020. Researchers surveyed critical care nurses about their experiences with medication titration, use of clinical judgment when titrating, nurses’ scope and autonomy, and their moral distress. Of 781 respondents, 80% perceived the titration standards caused delays in patient care and 68% reported suboptimal care, both of which significantly and strongly predicted moral distress.
McComb SA, Lemaster M, Henneman EA, et al. J Patient Saf. 2017;13:237-242.
… Journal of patient safety … J Patient Saf … Interprofessional collaboration is a cornerstone of safe patient care. Researchers surveyed … the other profession when compared to their own. Fostering a shared mental model and mutual trust are core components of …
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.
Henneman EA, Tessier EG, Nathanson BH, et al. J Patient Saf. 2014;10:88-94.
Medication reconciliation efforts depend on obtaining an accurate medication history at the time of the clinical encounter. In this study, use of a structured tool by student nurses improved the accuracy of the medication history at hospital admission and was associated with fewer inadvertent medication omissions.
Blank FSJ, Tobin J, Macomber S, et al. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2011;37:141-7.
An educational intervention for emergency department nurses improved knowledge of safe medication administration principles, but did not reduce the actual incidence of medication errors.
Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.
… study explored the cues that nurses use to determine when a patient's clinical condition is worsening, with specific attention to … to obtain assistance from the rapid response team or call a "code blue." Rather than relying on specific vital sign …
Henneman EA. AACN Adv Crit Care. 2009;20:128-132.
… the scope of the term patient safety technology and uses a case study to illustrate that sometimes simple … solutions can greatly improve patient safety. … Henneman EA. Patient safety and technology.  AACN Adv Crit …
Caglar S, Henneman PL, Blank FS, et al. J Emerg Med. 2011;40:613-6.
… The Journal of emergency medicine … J Emerg Med … Patient medication lists obtained by emergency … staff frequently contained errors when compared to a "gold standard" list. This finding has implications for …
Blank FSJ, Santoro J, Maynard AM, et al. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2007;33:331-5.
J Emerg Nurs … Journal of emergency nursing: JEN : official … Department Nurses Association … The authors describe a program involving periodic reassessments of patients in the …
WebM&M Case May 1, 2007
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.