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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 - 19 of 19 Results
Arbaje AI, Werner NE, Kasda EM, et al. J Patient Saf. 2020;16:52-57.
Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.
Pronovost P, Holzmueller CG, Molello NE, et al. Acad Med. 2015;90:1331-9.
Academic medical centers can serve as educational leaders in patient safety improvement. This commentary describes the development of the Armstrong Institute at Johns Hopkins which generated multidisciplinary educational programs and research opportunities that engaged clinicians, administrators, and patients in setting goals to improve safety at their institution. The authors provide insights regarding establishing a safety governance structure, setting a committee agenda, and implementing and evaluating interventions.
Headrick LA, Barton AJ, Ogrinc G, et al. Health Aff (Millwood). 2012;31:2669-2680.
A seminal 2009 report describes the lack of formal curricula in patient safety and quality improvement in medical education as an unmet need, and similar concerns have been raised about nursing and pharmacy education. This study reports on an initiative to develop interprofessional curricula in patient safety, involving both nursing and medical students, at six institutions across the country. Although the institutions encountered many challenges—including a lack of faculty expertise in patient safety—they were able to implement several novel curricula that were well-received by students. However, the authors note that because there are no well-validated means of evaluating students' knowledge and skills in patient safety, their ability to draw conclusions about the effectiveness of interprofessional curricula was limited.
Pronovost P, Rosenstein BJ, Paine LA, et al. Jt Comm J Qual Patient Saf. 2008;34:342-8.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The ability to measure and track … required to accomplish such goals. In this commentary, Dr. Peter Pronovost and colleagues describe the sequential …
Pronovost P, Holzmueller CG, Needham DM, et al. Crit Care Med. 2006;34:1988-95.
This study provides an evaluative framework for addressing whether our health care system is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how often do we harm patients, how often do patients receive the appropriate interventions, how do we know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to evaluate health care quality, the authors present a detailed discussion of attributes necessary for safety-specific measures. They provide a case-type example of their suggested process to illustrate their framework. Reflecting on the 5 years since release of the IOM report, past commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide further context to the efforts of this study.