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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 - 11 of 11 Results
Jones AM, Clark JS, Mohammad RA. Am J Health Syst Pharm. 2021;78:818-824.
Burnout has been a focus of numerous studies since the beginning of the COVID-19 pandemic; however, this is the first to focus on burnout and secondary traumatic stress (STS) among health system pharmacists. Nearly two thirds (65.3%) of respondents had a moderate to high likelihood of experiencing burnout and 51% had a high probability of STS. Due to the association between burnout and decreased patient safety, it is critical that health systems address pharmacist burnout appropriately.
Marella WM, Sparnon E, Finley E. J Patient Saf. 2014;13:31-36.
Voluntary error reporting systems are an important part of safety improvement programs, but difficulty in analyzing error reports has limited their utility. This study described the development of a machine learning algorithm to analyze free-text data in incident reports. The algorithm proved to be accurate in classifying events when compared to manual review.
Pham JC, Williams TL, Sparnon EM, et al. Respir Care. 2016;61:621-31.
Using ventilator-associated adverse events as a test case, this study illustrates how the public–private partnership for the promotion of patient safety concept can augment understanding of patient safety issues. The group successfully developed a common taxonomy for evaluating adverse events from three different reporting systems.
Pham JC, Gianci S, Battles J, et al. Qual Saf Health Care. 2010;19:446-51.
Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.
Grissinger MC, Hicks RW, Keroack MA, et al. Jt Comm J Qual Patient Saf. 2010;36:195-202.
Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-8, 221-2.
This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.
Marella WM, Finley E, Thomas AD, et al. J Patient Saf. 2008;3.
Patients are increasingly being asked to assume a role in ensuring their own safety. Both AHRQ's "20 Tips to Help Prevent Medical Errors" and the Joint Commission's "Speak Up" program to ensure surgical safety recommend that patients engage in specific safety practices, such as maintaining a list of their medications and asking health care workers if they have washed their hands. This survey assessed the willingness of patients to carry out these practices. Patients were much less likely to engage in behaviors that required them to challenge providers (such as checking for handwashing compliance) than less confrontational practices (such as following up on test results). The study's findings are similar to a prior AHRQ-funded study of patients recently discharged from the hospital.
Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-403, discussion 403-5.
This study examined instances of wrong-site surgery reported to authorities in Pennsylvania and sought to determine factors contributing to the error.