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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 - 7 of 7 Results
Nuckols TK, Bell D, Paddock SM, et al. Jt Comm J Qual Patient Saf. 2009;35:139-45.
Incident reporting (IR) systems serve as an important mechanism to understand, analyze, and potentially prevent errors in the hospital setting, though their utility has been questioned. This study categorized more than 2200 incident reports into whether they described aberrant care processes, undesirable outcomes, or both. Investigators found that 50% were only process-oriented and that these were more useful than solely outcome-oriented reports because the former helped identify preventability and relevant contributing factors. The authors advocate for hospitals to focus their IR systems on process-driven reports that encourage staff to highlight factors amenable to improvement interventions.
Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23 Suppl 1:41-5.
Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.
Nuckols TK, Paddock SM, Bower AG, et al. Med Care. 2009;46:17-24.
This study discovered that adverse drug events (ADEs) associated with intravenous administration led to increased hospital costs and length of stay, but only in academic centers. Investigators conducted chart reviews for more than 4600 patients in 5 different intensive care units, and present findings from nearly 400 ADEs identified. The majority of events led primarily to temporary physical injuries. In academic settings, the events were associated with more than $6600 in costs and a 4.8 day longer length of stay. The most notable finding was the lack of such differences in nonacademic settings. The authors discuss the differential findings in academic versus nonacademic settings, including how the limitations of their study design may have contributed.
Nuckols TK, Bell D, Liu H, et al. Qual Saf Health Care. 2007;16:164-8.
… filed by nurses, with less than 2% filed by physicians (a problem noted in prior research ). This pattern likely influenced the spectrum of problems reported; only a small proportion of reported incidents related to procedures. A prior commentary proposed a theoretical framework for using …
Fein SP, Hilborne LH, Spiritus EM, et al. J Gen Intern Med. 2007;22:755-761.
… and nurses to analyze how practitioners would describe a hypothetical error that caused patient harm. Respondents … clearly link the error and the adverse clinical outcome, a phenomenon also noted in prior research . The authors propose a formal definition of error disclosure, which incorporates …