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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 - 3 of 3 Results
Farley DO, Haviland A, Champagne S, et al. Qual Saf Health Care. 2008;17:416-23.
Reducing adverse events on an institutional level requires a comprehensive error-reporting system and effective mechanisms for analyzing data and implementing solutions. This AHRQ-funded study evaluated the quality of more than 1600 hospitals' error-reporting systems. Four key components of effective reporting systems were identified: a supportive environment for reporting, reports received from a broad range of staff, timely dissemination of reports, and structured mechanisms to review reports. Results indicate that, by these criteria, the majority of hospitals do not have effective systems in place to identify errors. Specifically, only a small proportion of hospitals have a safety culture that encourages reporting or promptly disseminate and analyze error reports. These results mirror concerns about standard incident-reporting systems that have been raised in prior studies. An accompanying editorial discusses the optimal role for incident reporting among error detection and prevention strategies.
Battles JB, Kaplan HS, van der Schaaf TW, et al. Arch Pathol Lab Med. 1998;122:231-8.
This article describes an effort to design, develop, and implement a medical event reporting system for transfusion medicine-related incidents and errors. Using a combination of methods, a working prototype went into use with seven distinct components, including detection, selection, description, classification, interpretation, and local evaluation. The authors conclude that developing event-reporting systems can help organizations address systems issues, while input from end users drives both the model and the necessary improvements.