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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 - 4 of 4 Results
Carmack HJ. Health Comm. 2020;35:1466-1474.
Large-scale system failures can damage an organization's credibility. This commentary analyzes how one organization responded after an incident that involved 76 patients who mistakenly received fatally high doses of radiation. The strategies discussed center on the importance of organizational communication to patients, navigating the blame response, and rapid efforts to prevent similar events.
Noland CM, Carmack HJ. Qual Health Res. 2015;25:1423-34.
This qualitative study examined narratives of nursing students' errors and found three common themes: "save the day" narratives (nurses recognize and mitigate physician errors), "silence" narratives (nurses do not disclose errors to patients), and "not always right" narratives (students were able to challenge supervisors). These narratives underscore the importance of a positive safety culture for identifying and mitigating errors in real time.
Carmack HJ. Qual Health Res. 2014;24:860-869.
Clinicians who are involved in a medical error and experience considerable emotional distress, shame, and self-doubt are considered second victims. This commentary used interviews with physicians and administrators involved in a hospital's disclosure and apology program to determine the emotional process physicians undergo after committing and disclosing a medical error.