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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 - 7 of 7 Results
Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.
System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.
Buckley MS, Rasmussen JR, Bikin DS, et al. Ther Adv Drug Saf. 2018;9:207-217.
This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.
Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.
This study describes the development of an open-ended survey tool administered to anesthesia providers at the conclusion of surgical cases, with the goal of contemporaneously identifying adverse events. The tool identified a broader array of adverse events and near misses than the traditional incident reporting system.
Cook R, Rasmussen J. Qual Saf Health Care. 2005;14:130-4.
Health care systems continue to evolve with greater complexity and attention to system-based improvement efforts. This article explores ongoing shifts in care delivery operations and the potential they create for accidents. Discussion includes both written and graphic descriptions of a dynamic safety model, explanation of "tightly coupled" systems, and the associated reactions and consequences of providing care in these types of systems. The authors conclude that improvements in organizational efficiency have led to "going solid," which poses new challenges and barriers to patient safety.
Rasmussen J. Philos Trans R Soc Lond B Biol Sci. 1990;327:449-462.
Reporting on a growing trend toward large and complex systems, this article explores the role of human error in system safety redesign. With the evolution of systems described, arguments are made for challenges in linking errors as a specific behavior rather than an effect of changing work environments. Discussion includes the causal analysis of accidents, human error and behavior, human and system adaptation, and control of safety in complex systems. Based on presented information, the author calls for new system design approaches with greater emphasis on addressing structural deficiencies rather than human reliability.
Rasmussen J. Qual Saf Health Care. 2003;12:377-383.
In this article, Rasmussen presents the concept of human error, and how complex and dynamic environments should shift the focus of error. The author argues for a general understanding of human behavior and social interactions in cognitive terms. He presents three cases to analyze human–system interactions, including traditional task analysis and human reliability, causal analysis after an event, and design of reliable work conditions in modern sociotechnical systems. Rasmussen highlights the need for errors to be studied in the context of cognitive control of behavior in complex environments.