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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 - 6 of 6 Results
Klein DO, Rennenberg RJMW, Koopmans RP, et al. J Patient Saf. 2021;17:e1234-e1240.
The Harvard Medical Practice Study (HMPS) and the Institute for Healthcare Improvement Global Trigger Tool (GTT) are two of the most widely used trigger tools to identify adverse events and prompt medical record review. Fifty studies using either trigger tool to prompt a medical record review (MRR) for potentially preventable adverse events were included in this literature review. MRR reveals more adverse events than other methods; however, research is still lacking or is of moderate quality. 
Klein DO, Rennenberg RJMW, Koopmans RP, et al. BMC Health Serv Res. 2019;19:16.
This retrospective study evaluated the performance of a trigger tool in detecting safety problems in inpatients. Researchers examined the records of deceased patients and found that the trigger tools flagged many patient records in which no adverse event had occurred. This high false-positive rate led them to conclude that trigger tools are too labor-intensive to be feasible for real-world detection of safety hazards.
Silkens MEWM, Arah OA, Wagner C, et al. Acad Med. 2018;93:1374-1380.
Patient safety is an increasing area of focus within graduate medical education. Using data on residency educational climate, patient safety climate, and residents' self-reported patient safety behaviors from 31 teaching hospitals in the Netherlands, researchers found an association between safety climate and self-reported patient safety behavior.
de Feijter JM, de Grave WS, Muijtjens AM, et al. PLoS One. 2012;7:e31125.
Patient safety professionals and directors of health care organizations must be able to prioritize among safety initiatives, which requires knowing which safety problems are most prevalent within an institution. However, as this cohort study conducted at a Dutch hospital shows, single error detection methods are unable to provide a comprehensive picture of patient safety. Comparing adverse events detected by the hospital's voluntary incident reporting system, retrospective chart review, and patient complaints, this study found that the type and severity of safety issues varied between detection methods, with little overlap of identified incidents. Similar findings were noted in a prior study conducted at an American tertiary care hospital, and an editorial that accompanied that study provides a comprehensive overview of the strengths and weaknesses of different types of error detection systems.