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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
Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.
Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.
Thomas AD, Pandit C, Krevat S. J Patient Saf. 2023;19:67-70.
Previous research has identified disparities in adverse events and patient safety risks for Black patients compared to White patients. In this study, researchers used a large healthcare system’s malpractice database to examine racial differences in malpractice lawsuits. Although there were no significant race differences in lawsuits, findings suggest that employees are more likely to identify potential malpractice events for White patients compared to Black patients.
Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.
Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.
Thomas AD, Pandit C, Krevat S. J Patient Saf. 2021;17:e1605-e1608.
J Patient Saf … Building on prior research , this study … handling, blood bank, and safety/security. … Thomas AD, Pandit C, Krevat SA. Race differences in reported "near miss" … in health care system high reliability organizations. J Patient Saf. 2021;17(8):e1605-e1608. …
Cook TM, Andrade J, Bogod DG, et al. Anaesthesia. 2014;69:1102-1116.
Reviewing data reported from every public hospital in the United Kingdom and Ireland regarding accidental patient awareness during anesthesia, this study revealed that distress and longer-term harm were prevalent in such incidents despite their short time duration (most lasted less than 5 minutes). The majority of cases were found to be preventable, emphasizing the need to avoid these events.

Paasche-Orlow MK, Wilson EAH, McCormack L, eds. J Health Comm. 2010;15(suppl 2):1-225.

… . … Paasche-Orlow MK, Wilson EAH, McCormack L, eds. J Health Comm . 2010;15(suppl 2):1-225. … Wilson EAH; Vom … … SM … L … E … D … A … K … KA … RL … RL … SJ … TR … DE … M … LE … U … AJ … JY … NE … R … A … TW … LM … D … S … BW … R … … Schillinger … Ohene-Frempong … Hibbard … Clayman … Pandit … Bergeron … Cameron … Ross … Yost … Webster … Baker … …
Bailey SC, Pandit AU, Yin S, et al. Fam Med. 2009;41:715-21.
This survey revealed that many adults do not understand instructions for common liquid prescription medications, potentially increasing the risk of serious medication errors. Prior research in this field has demonstrated that low health literacy is an important predictor of misunderstanding prescription instructions. Concerningly, in this study nearly 1 in 5 patients who had adequate health literacy could not correctly interpret the instructions, and patients with marginal or low health literacy were at even greater risk. A previous WebM&M commentary discusses safety problems caused by low health literacy.