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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 - 10 of 10 Results
Ramsey L, Albutt AK, Perfetto K, et al. Int J Equity Health. 2022;21:13.
Patients with learning disabilities encounter unique patient safety threats. This qualitative study explored the care experiences and safety concerns of people with learning disabilities and their caregivers. Researchers identified several protective factors to avoid safety inequities and support safe, high-quality care, including access to social support and advocacy, appropriate staffing, sufficient expertise in care settings, care continuity, and accommodations of individualized care and communication needs.
Lamming L, Montague J, Crosswaite K, et al. BMC Health Serv Res. 2021;21:1038.
Patient safety huddles are used to promote team communication about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers concluded that patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety culture, especially for nurses.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23:549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.
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.
Louch G, Mohammed MA, Hughes L, et al. Health Expect. 2019;22:102-113.
The Patient Reporting and Action for a Safe Environment (PRASE) study was a large patient engagement intervention that proactively solicited hospitalized patient feedback about their safety. This qualitative study found that hospital volunteers could use PRASE tools to sustainably solicit patient feedback in place of paid study staff. However, health care workers did not consistently have means to act upon the safety hazards that patients and volunteers identified. A recent PSNet interview with Rebecca Lawton, lead investigator on the PRASE study, discussed her experience and insights in patient engagement research.
Louch G, O'Hara JK, Mohammed MA. Health Expect. 2017;20:1143-1153.
This qualitative evaluation found that a volunteer-administered patient engagement intervention was received positively by patients, families, volunteers, and frontline staff. The authors suggest that this intervention is a promising approach to enhance patient engagement.
Schmidt PE, Meredith P, Prytherch DR, et al. BMJ Qual Saf. 2015;24:10-20.
Many patients show physiological signs of worsening for several hours prior to requiring more aggressive interventions and transfer to a higher level of care. Rapid response teams have been widely deployed to address this problem, but this approach is fundamentally reactive rather than proactive and has had mixed results so far. This time series study utilized an electronic physiological surveillance system—a real-time decision support system based on patients' vital signs—embedded within the electronic medical record to provide guidance for clinicians in determining patients at risk for deterioration and optimizing treatment intensity. Implementation of the electronic physiological surveillance system was associated with a statistically significant reduction in mortality for a broad range of diagnoses at both hospitals. The results of this study illustrate the potential of novel information technology approaches for prospectively identifying patients at risk for clinical harm.