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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 38 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.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.
Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;78:458-478.
… errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors … care service. … Kelly FE, Frerk C, Bailey CR, Cook TM, Ferguson K, Flin R, et al. Implementing human factors in anaesthesia: guidance …
Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;78:479-490.
Human factors science focuses on designing systems that make it easy for workers to do the right thing and difficult to do the wrong thing. This narrative review focuses on human factors science in anesthesia. Research is described as it relates to the hierarchy of controls model: design, barriers, mitigations, education, and training.
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2023;38:26-32.
Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 
Zestcott CA, Spece L, McDermott D, et al. J Racial Ethn Health Disparities. 2021;8:230-236.
Implicit bias can contribute to poor decision-making and lead to poor patient outcomes. This qualitative study found that many healthcare providers have negative implicit attitudes about American Indians, such as implicitly stereotyping American Indians as "noncompliant" patients. The effect of these implicit attitudes and stereotypes was moderated by self-reported cultural competency and implicit bias training.
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.
Holden RJ, Campbell NL, Abebe E, et al. Res Social Adm Pharm. 2020;16:54-61.
This usability study examined whether older adults could use a mobile application to consider the risks and benefits of anticholinergics, a high-risk medication class. The 23 participants reported an overall high usability for the application, suggesting that mobile health information technology has potential to engage patients in safety.
Ferguson C, Hickman L, Macbean C, et al. J Clin Nurs. 2019;28:2365-2368.
Patient misidentification can result in incorrect diagnosis, treatment, and medication administration. This commentary discusses the practice of auditing patient identification wristbands to assess compliance and accuracy. The authors suggest that technological interventions such as smartphone facial recognition and barcode technologies be considered as strategies to avoid patient misidentification.
Eichbaum Q, Adkins B, Craig-Owens L, et al. Diagnosis (Berl). 2019;6:249-257.
… Germany) … Diagnosis (Berl) … Morbidity and mortality (M&M) conferences were traditionally promoted as a strategy to … events. Researchers conducted a retrospective review of 49 M&M rounds cases in the pathology department of a single medical center and found …
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
Fleming CA, Humm G, Wild JR, et al. Int J Surg. 2018;52:349-354.
This survey of surgical trainees found that the majority had witnessed practices or behaviors among colleagues that posed risks to patient safety, including poor performance and disruptive behavior. However, a large proportion reported that they had failed to escalate these concerns, as well as concerns about unsafe systems of care, due to fear of reprisal or negative effects on their career. The study points to the need to improve the culture of safety within surgical training.
Ferguson CC. JAMA Pediatr. 2017;171:1141.
In this commentary, a physician recounts a mistake that led to an infant patient's death, critical statements made by senior faculty members after the incident, and feeling shame that affected her work and home life. The piece discusses approaches for enabling other clinicians to manage shame associated with poor outcomes through disclosure, introspection, and compassion for the fallibility of care providers.

McDonnell WM; Altman RL; Bondi SA et al for the Committee on Medical Liability and Risk Management; Council on Quality Improvement and Patient Safety. Pediatrics. 2016;138(6);e20163215.

… … WM … RL … SA … JM … SK … RL … JW … KA … JP … SM … WH … T … DG … LE … SP … M … BU … DR … ML … RN … JS … McDonnell … Altman … Bondi … … Santucci … Scibilia … Scott … Franklin … Adirim … Bundy … Ferguson … Gleeson … Leu … Mueller … Neuspiel … Rinke … …