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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 54 Results
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.
Shiell A, Fry M, Elliott D, et al. Intensive Crit Care Nurs. 2022;73:103294.
Rapid response team (RRT) activations bring together a team of providers to immediately assess and treat a patient who is rapidly deteriorating. This mixed-methods study examined the characteristics of a collaborative RRT model in one Australian tertiary care hospital. The majority of activations occurred in general medicine units and some patients (approximately 5%) had more than five activations. Qualitative interviews with nurses and physicians highlighted how the collaborative RRT model improves patient safety and optimized early detection and management of patient deterioration.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
J Patient Saf Risk Manag … The July effect is a phenomenon … Vincent C, Shapiro DW, et al. Mitigating the July effect. J Patient Saf Risk Manag. 2021;26(3):93-96. …
Vasey B, Ursprung S, Beddoe B, et al. JAMA Netw Open. 2021;4:e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.
Greenberg N, Weston D, Hall C, et al. Occup Med (Lond). 2020;71:62-67.
The burden of the COVID-19 pandemic has placed healthcare workers at higher risk for poor mental health outcomes. This survey of doctors, nurses, and other healthcare staff working in intensive care units (ICUs) identified significant rates of probable mental health disorders and thoughts of self-harm. These findings reinforce the need to support the emotional well-being of healthcare workers during this crisis.

Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

… Impact Team; Al Hassan Z; Antar M, Alshehri A … CE … CM … J … MA … S … A … AM … J … MA … R … M … PL … LC … SH … MI … E … … R … S … R … C … T … F … S … M … L … P … M … B … A … W … KK … RJ … K … C … A … C … P … S … RP … SJ … LL … MD … V … … Alali … Kazzaz … Chu … Lin … Tung … Clinciu … Dick-Smith … Elliott … Martinez-Maldonado … Power … Haug … Holte … Chang … …
Elliott RA, Camacho E, Jankovic D, et al. BMJ Qual Saf. 2021;30:96-105.
This study combined previously published error prevalence estimates in the United Kingdom to estimate the annual number and burden of medication errors to the National Health Service (NHS). The authors estimate that 237 million medication errors occur annually in the UK. The majority of errors occur during medication administration and prescribing and occur most frequently in long-term care and primary care settings. While the majority of errors have little or no potential for harm, 66 million errors were deemed potentially clinically significant; prescribing in primary care settings accounts for one-third of these potentially significant errors. These medication errors result in hospital admissions or longer length of stay, as well as death. 
Hashmi ZG, Haut ER, Efron DT, et al. JAMA Surg. 2018;153:686-689.
Determining which harms are truly preventable remains an ongoing challenge in the field of patient safety. In a 2016 report, the National Academies of Sciences, Engineering, and Medicine called for achieving zero preventable trauma deaths, but the actual number of preventable trauma deaths in the United States remains unknown. Analyzing administrative data from more than 18 million patients across 2198 hospitals, investigators determined that if low-performing hospitals could provide the same quality of trauma care as high-performing centers, 100,000 lives could be saved over a 5-year period.
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
… in which a medication error led to serious patient harm. … Elliott RA, Camacho E, Campbell F, et al. Policy Research … Interventions; EEPRU … RA … E … F … D … E … R … MJ … R … Elliott … Camacho … Campbell … Jankovic … Kaltenthaler … Wong … Sculpher … Faria … RA Elliott … E Camacho … F Campbell … D Jankovic … E …
WebM&M Case November 1, 2016
… with no major permanent injuries. … The Commentary … by Elliott K. Main, MD … Obstetric hemorrhage is the most common serious … in postpartum hemorrhage: United States 1994–2006. Am J Obstet Gynecol. 2010;202:353.e1-353.e6. [go to PubMed] 6. …