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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 - 13 of 13 Results
Wong CI, Vannatta K, Gilleland Marchak J, et al. Cancer. 2023;129:1064-1074.
Children with complex home care needs, such as children with cancer, are particularly vulnerable to medication errors. This longitudinal study used in-home observations and chart review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced adverse drug events due to medication errors in the home and 42% experienced a medication error with the potential for harm. Failures in communication was the most common contributing factor. Findings underscored a critical need for interventions to support safe medication use at home. Researchers concluded that improvements addressing communication with and among caregivers should be co-developed with families and based on human-factors engineering.
Tubbs-Cooley HL, Mara CA, Carle AC, et al. JAMA Pediatr. 2019;173:44-51.
… pediatrics … JAMA Pediatr … Excessive nursing workload is a known safety issue. This study examined whether nurse … ratios , taking into account patient acuity, and a convenience sample of nurses also reported their perceived … essential elements of nursing care. The authors identified a consistent association between perceived workload and …
Tubbs-Cooley HL, Pickler RH, Younger JB, et al. J Adv Nurs. 2015;71:813-24.
This study surveyed nurses in neonatal intensive care units about missed nursing care. As in other care settings, missed nursing care is significant, and reasons include interruptions, urgent patient situations, and increases in patient volume. This finding underscores the need to enhance nursing workflow to prevent errors of omission.
Jennings BM, Sandelowski M, Mark BA. Qual Health Res. 2011;21:1441-51.
This ethnographic study describes the complexity of medication administration and competing demands affecting nurses' workdays.
Chang YK, Mark BA. Nurs Res. 2010;60.
… staffing and the safety of inpatient care is supported by a large body of literature . In addition to staffing ratios, safety culture has also been found to be a determinant of errors. This study explored the links … culture, and medication errors, and found evidence for a complex relationship. The learning climate (a component of …
Bae S-H, Mark BA, Fried B. Health Care Manage Rev. 2010;35:333-344.
… tied to patient safety, prior research has not found a link between the proportion of temporary nurses and patient care outcomes. This study, based on a database of 286 nursing units, also found that patient … for appropriate use of temporary nurses. … Bae SH, Mark B, Fried B. Use of temporary nurses and nurse and …
Chang Y-K, Mark BA. J Nurs Scholarsh. 2009;41:70-8.
This study examined factors contributing to medication errors and discovered that severe and nonsevere errors differ in their antecedents. The authors suggest that different prevention strategies may be necessary for each error type.