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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 34 Results
Berwick DM. JAMA. 2021;326:2127-2128.
Efforts to improve diagnosis recognize the value in patient-centered care. This commentary outlines how a diagnostician can enfold patient centeredness into their practice, which includes the seeking of knowledge and moderation of actions taken to arrive at a diagnosis. This piece is part of a series on diagnostic excellence.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Classen DC, Griffin FA, Berwick DM. Ann Intern Med. 2017;167.
Electronic health records have been widely adopted in both inpatient and outpatient settings. This commentary suggests that health information technology provides health care with an opportunity to optimize patient safety measurement in hospitals and that barriers such as data collection burden, mismatched definitions, and ineffective methods of tracking patient harm can be addressed through robust electronic health record design and use.
Gandhi TK, Berwick DM, Shojania KG. JAMA. 2016;315:1829-30.
This commentary discusses findings from the National Patient Safety Foundation report investigating the state of patient safety in the 15 years after To Err Is Human. Focusing on the recommendation that leadership establish and sustain a culture of safety, the authors describe how leaders can engage board members and organizational leadership in this work and highlight the need to provide leaders with education and practical tools.
Davies L, Batalden P, Davidoff F, et al. BMJ Qual Saf. 2015;24:769-75.
The SQUIRE Guidelines were developed to promote rigor in the reporting of quality improvement initiatives. Using focus groups and individual interviews, investigators found that the guidelines were useful for planning projects, but overly complex for writing or presenting quality improvement work. This suggests that the revision of the guidelines should be simplified and clarified to enhance its use.
Perspective on Safety September 1, 2012
This piece describes federal initiatives aimed at preparing the nursing workforce needed to match future demand and to navigate changes vital to improving health care.
This piece describes federal initiatives aimed at preparing the nursing workforce needed to match future demand and to navigate changes vital to improving health care.
Prof. Needleman has performed some of the key studies on how the nursing workforce influences health outcomes, including seminal articles published in the New England Journal of Medicine in 2002 and 2011.
WebM&M Case November 1, 2011
Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.
Clancy CM, Berwick DM. Ann Intern Med. 2011;154:699-701.
Accompanying a consensus statement, this editorial discusses the challenges of conducting research in complex settings, and notes existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.
McCannon J, Berwick DM. JAMA. 2011;305:2221-2.
Highlighting goals and strategies of the Partnership for Patients program, this commentary discusses challenges to improving patient safety.
Needleman J, Buerhaus P, Pankratz S, et al. New Engl J Med. 2011;364:1037-1045.
… ensure adequate levels of nurse staffing. … Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality.  N Engl J …
Litvak E, Pronovost P. JAMA. 2010;304:1375-6.
This commentary discusses problems such as triage error, patient flow, and patient–unit mismatches as situations that precipitate the need for rapid response teams (RRTs). Due to a lack of data supporting the effectiveness of RRTs, the authors advocate for addressing these underlying systematic problems within hospitals.
Ogrinc G, Davies L, Goodman D, et al. BMJ Qual Saf. 2016;25:986-992.
The rapid growth in literature on patient safety and quality improvement (QI) has been accompanied by controversy about how such studies should be conducted and reported. Influential leaders have argued that QI studies demand a different standard of evaluation than traditional biomedical research, given their complexity. A contrary argument notes that failure to rigorously evaluate such research could result in wasted resources and unanticipated consequences if poorly evaluated interventions are widely implemented. Developed by expert consensus, these guidelines provide a blueprint for reporting the results of QI studies. Since its introduction in 2008, authors and journal editors have widely adopted these guidelines to standardize reporting of safety and QI studies. In 2015, the SQUIRE guidelines were revised through a process that included semistructured interviews, focus groups, consensus meetings, pilot testing with authors, and a public comment period. SQUIRE 2.0 improves the usability of the guidelines and omits the multiple sub-items that were felt to be too confusing for authors in the initial document.
Berwick DM. JAMA. 2008;299:1182-4.
… JAMA … JAMA … This commentary by Dr. Donald Berwick, president of the Institute for Healthcare … discussed his career in patient safety in an AHRQ WebM&M conversation in 2005. …
Grol R, Berwick DM, Wensing M. BMJ. 2008;336:74-6.
This article addresses the gap in health care quality and safety research and offers a list of topics for future study. The authors argue that the research community's attitude about this field of study must change.
Taylor CR, Hepworth JT, Buerhaus P, et al. Qual Saf Health Care. 2007;16:244-7.
A crew resource management teamwork training intervention was implemented at an urban primary care clinic, with the goal of improving care for diabetes patients. The effort resulted in short-term improvements in adherence to evidence-based care processes for diabetes.