Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 26 Results
Horsky J, Aarts J, Verheul L, et al. Int J Med Inform. 2017;97:1-11.
Prior research has shown that providers frequently override drug interaction alerts, sometimes as a result of alert fatigue. In this study, researchers observed providers as they completed medication orders, addressing both high- and low-severity drug interaction alerts using five distinct electronic health records in two countries. The authors found that providers engaged in complex clinical reasoning prior to declining an alert, balancing various aspects of patient care including safety- and patient-specific factors.
WebM&M Case August 21, 2016
Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.
Patel VL, Kannampallil TG, Shortliffe EH. BMJ Qual Saf. 2015;24:468-474.
Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A Perspective interview with Dr. Pat Croskerry explored the role of cognition in medical error.
Abraham J, Kannampallil TG, Patel VL. J Am Med Inform Assoc. 2014;21:154-62.
The patient safety risks associated with handoffs have been well documented. As a result, multiple investigators have developed standardized tools to improve the quality of information transfer during handoffs. What remains unclear is the extent to which standardizing the handoff process improves patient safety. This systematic review of 36 studies examining the effectiveness of handoff tools found that most tools were not evaluated rigorously and did not specifically assess the effect of standardizing handoffs on patient-level outcomes. Therefore, the authors were unable to reach conclusions regarding the optimal methods for improving the quality of handoffs. Similar problems were noted in studies of checklists, another widely implemented safety intervention, highlighting both the difficulty and the importance of strictly evaluating patient safety interventions.
Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-23.
This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.