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.
Abdallah W, Johnson C, Nitzl C, et al. J Health Organ Manag. 2019;33:695-713.
Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.
Joffe E, Turley JP, Hwang KO, et al. BMJ Qual Saf. 2014;23:398-405.
Clinicians must routinely triage and manage clinical issues over the telephone, but prior research has shown that this process is often error-prone. This simulation study of telephone triage in hospitalized patients found bidirectional problems with communication, as nurses frequently failed to provide crucial information and physicians did not take appropriate action even when properly informed.
Joffe E, Turley JP, Hwang KO, et al. Jt Comm J Qual Patient Saf. 2013;39:495-501.
The SBAR (situation, background, assessment, recommendation) communication tool has been implemented in an effort to improve nurse–physician communication, particularly by telephone. For this simulation study, 20 nurse–physician pairs were enrolled and the nurse in each pair was randomized to receive six written clinical scenarios to convey to the physician (three using the SBAR format, three in the usual format). Investigators found that relevant information was often not communicated by the nurse nor elicited by physicians, and use of SBAR did not improve communication.
Turley JP, Johnson TR, Smith DP, et al. Jt Comm J Qual Patient Saf. 2006;32:214-20.
The investigators analyzed operating manuals of five infusion pumps to evaluate their usability. The authors suggest that such manuals can be used to inform purchasing decisions when the actual device cannot be tested.
Laxmisan A, Malhotra S, Keselman A, et al. J Biomed Inform. 2005;38:200-12.
Using the concepts of "sharp" and "blunt" ends of practice, this article explores health professionals' differing opinions on biomedical device-related errors. Investigators requested that study participants express their views on events surrounding three true-error scenarios. Analysis of the transcribed responses revealed that interpretation varied widely between groups. While clinicians focused on clinical and human factors, biomedical engineers focused on device-related issues, and administrators emphasized documentation and training. The authors conclude that individual expertise largely mediates an error analysis, as no single interpretation provides a comprehensive view of all contributing factors.