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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 22 Results
Weggelaar-Jansen AMJWM, Broekharst DSE, de Bruijne M. BMJ Qual Saf. 2018;27:1000-1007.
Using dashboards to provide real-time quality and safety data to frontline providers can enhance adherence to practices promoting safety. In this retrospective study, researchers examined the process of developing hospital-wide quality and safety dashboards in Dutch hospitals.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25:385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
Romijn A, Teunissen PW, de Bruijne M, et al. BMJ Qual Saf. 2018;27:279-286.
This qualitative study assessed perceptions of teamwork and interprofessional collaboration between obstetricians, nurses, and hospital-based and primary care midwives in the Netherlands. Overall, obstetricians perceived teamwork to be better than participants from other disciplines. The gap between physicians, nurses, and midwives was largest with regard to perceived openness to sharing opinions and discussing new ideas.
Eindhoven DC, Borleffs JW, Dietz MF, et al. BMJ Open. 2017;7:e014360.
Although adverse events among hospitalized patients are common, less is known about the safety of acute cardiac care. In this retrospective study, researchers described the development and validation of a tool to assess the safety of patients treated for acute myocardial infarction.
van Rosse F, Suurmond J, Wagner C, et al. BMJ Open. 2016;6:e009052.
This study used interviews with health care providers, patients, and caregivers to explore the safety issues associated with limited language proficiency. Caregivers often had to assume roles (such as interpreting) that had the potential to impair patient safety. A WebM&M commentary discussed a serious medication error arising from a language barrier.
Kemper PF, de Bruijne M, van Dyck C, et al. BMJ Qual Saf. 2016;25:577-87.
This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.
Baines RJ, Langelaan M, de Bruijne M, et al. BMJ Open. 2015;5:e007380.
Comparing adverse event reports from patients who died in the hospital versus patients discharged alive, this chart review study found that preventable adverse events were more likely among those who died. The authors suggest that examining deaths alone does not provide a complete picture of the epidemiology of adverse events and recommend review of multiple outcome types.
Baines RJ, Langelaan M, de Bruijne M, et al. BMJ Qual Saf. 2015;24:561-571.
This retrospective study in the Netherlands encompasses three national major adverse event studies. These authors previously reported that the adverse event rate in the Netherlands had increased between 2004 and 2008. In this current study, there was no change in overall adverse event rates in 2011/2012 compared to 2008, while preventable adverse events were markedly reduced by 45%. Following multiple adjustments, this decrease was still evident (30%), though no longer met statistical significance (p=0.10). The decreased harms were seen in areas addressed by national safety programs implemented during this time, suggesting a positive effect from these efforts. A related editorial by Charles Vincent and Rene Amalberti discusses the expanding scope of patient safety as more medical harms become regarded as preventable. A second editorial by two of the journal's editors discusses the degree to which the nonsignificant reduction in preventable adverse events plausibly represents improvements from a national patient safety program in the Netherlands. It also advances the idea that the results highlight some of the limitations of adverse events as a measure of progress in patient safety, a point also made in the editorial by Vincent and Almaberti.
van Rosse F, de Bruijne M, Suurmond J, et al. Int J Nurs Stud. 2016;54:45-53.
This mixed methods study of language barriers and patient safety found incomplete documentation of language proficiency and suboptimal use of professional language interpretation, consistent with prior studies. In a past AHRQ WebM&M interview, Dr. Dean Schillinger discusses safety and limited English proficiency.
Kemper PF, van Dyck C, Wagner C, et al. J Patient Saf. 2017;13:223-231.
Teamwork training has become a critical tool for promoting health care safety. This study describes the preparation, implementation, and impact of a crew resource management training program at three Dutch intensive care units. Following the training sessions, the participants launched several local quality improvement projects.
Poot EP, de Bruijne M, Wouters MGAJ, et al. J Eval Clin Pract. 2014;20:166-75.
This direct observation study of verbal handoffs in a labor and delivery ward revealed that key elements (situation, background, assessment, recommendation) of structured communication to address situational awareness were rarely implemented. However, participants reported satisfaction with handoff communication, suggesting that further education is needed.
Van Noord IV-, Wagner C, van Dyck C, et al. Int J Qual Health Care. 2014;26:64-70.
This survey revealed that physicians and nurses generally agreed about safety culture and practices, but physicians reported a higher patient safety grade. This study highlights the increasingly widespread use of safety culture surveys in clinical settings.
Baines RJ, de Bruijne M, Langelaan M, et al. BMC Health Serv Res. 2013;13:497.
Inadequate communication among multiple treating physicians may contribute to preventable adverse events. This study found that the risk of errors increases with the number of specialties treating a patient. A previous AHRQ WebM&M commentary described benefits and drawbacks associated with comanagement.
Kemper PF, van Noord I, de Bruijne M, et al. BMJ Qual Saf. 2013;22:586-95.
A new assessment tool, explicit professional oral communication (EPOC), for measuring non-technical skills of health care personnel was successfully validated in the emergency department and intensive care unit. Given that non-technical skills such as teamwork can positively affect safety outcomes, assessing and addressing this dimension of performance could yield significant safety benefits.
Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-21.
Evidence from autopsy studies indicates that thousands of patients die every year due to missed or delayed diagnoses, leading to diagnostic errors being termed the "next frontier" in patient safety. This Dutch study used trigger methodology (based on the classic Harvard Medical Practice Study) to analyze the epidemiology and underlying causes of diagnostic errors in a broad sample of hospitalized patients. Approximately 1 in 250 patients experienced a diagnostic error, most of which were considered preventable. The contributing factors primarily centered around knowledge-based errors and faulty information transfer between physicians—a problem noted in prior studies of diagnostic errors. A Patient Safety Primer discusses the heuristics that cause physicians to err in the diagnostic process and the system failures that lead to delayed or missed diagnoses.
van Noord I, de Bruijne M, Twisk JWR. Int J Qual Health Care. 2010;22:162-169.
Safety culture surveys focus on respondents' perception of safety in specific contexts, and measurement of safety culture is recommended in order to identify problem areas and targets for improvement. However, this Dutch study, conducted in 33 emergency departments, found that positive safety culture perception may actually inhibit implementation of recommended safety practices. For example, hospitals where respondents felt that handoffs and signouts were carried out safely were less likely to have standardized protocols for supervision or case review. This finding raises the concern that, in some cases, important safety mechanisms may not be implemented due to a false sense of security regarding patient safety.