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.
Ock M, Lim SY, Jo M-W, et al. J Prev Med Public Health. 2017;50:68-82.
This systematic review of disclosure of patient safety incidents found variation in the frequency of event disclosure. Motivation for disclosure included fostering trust with patients, reducing negative impact on health care professionals, and decreasing the risk of malpractice. Barriers to disclosure included fear of lawsuits and blame and a suboptimal patient safety culture. These results suggest that error disclosure remains incompletely implemented.
Lee JH, Han H, Ock M, et al. Int J Med Inform. 2014;83.
This before-and-after study found that clinical decision support reduced medication errors (greater than maximum dose) for five high-alert medications. Changes in order patterns emerged following the alerts, but the authors did not identify patient harm associated with the system. This work supports the use of clinical decision support for high-risk medications.