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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
Charles R, Hood B, DeRosier JM, et al. Patient Saf Surg. 2016;10:20.
Root cause analysis is a widely used strategy for understanding failure in patient care. This review highlights a root cause analysis method and describes tools such as story maps and cause-and-effect diagrams that support the use of this structured approach to examine process weaknesses and implement improvements.
Thompson DA, Marsteller JA, Pronovost P, et al. J Patient Saf. 2015;11:143-51.
This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery operating room, which jointly involved experts in organizational science, human factors, and clinical medicine. The authors detail the numerous methods they applied, including surveys, ethnographic direct observation, and analysis of a large database. Safety culture, teamwork and communication, infection prevention, handoffs, failure to adhere to standard practices, and environmental concerns were identified as six key hazards. This type of in-depth, multidisciplinary approach shows promise for determining and prioritizing safety approaches across various health care settings.
Perspective on Safety November 1, 2006
… more, there are an expanding set of resources.( 3 , 12 ) … John Gosbee, MD, MS … Human Factors Engineering and Healthcare … . Accessed November 1, 2006. … JohnGosbeeW. … John W. Gosbee … Dr. Robert Wachter, Editor, AHRQ …
Certain phrases are famously oxymoronic: "jumbo shrimp," "military intelligence." We chuckle at such terms, but they do little harm. In the patient safety field, the term "expected complication" is both defeatist and ultimately self-fulfilling. For that...
Don Norman, PhD, is well known for his books "The Design of Everyday Things" and "Emotional Design." Although not focused on health care, his work introduced many in health care to the concepts of human factors engineering and to the importance of thoughtful design in ensuring that technology is used for its intended purposes. He is cofounder of the Nielsen Norman Group, professor at Northwestern University, and former vice president of Apple Computer. Dr. Norman is now writing "The Design of Future Things," discussing the role that automation will play in our everyday lives. We asked Dr. Norman to speak with us about human-centered design.
DeVita MA, Bellomo R, Hillman KM, et al. Crit Care Med. 2006;34.
This article defines the key components of a "rapid response system" (RRS), which the authors propose as a unifying term for medical emergency teams, rapid response teams, and other similar teams designed to intervene on clinically unstable inpatients. An RRS should consist of an "afferent limb," the mechanism by which team responses are triggered; an "efferent limb," the team of clinicians that responds to an event; an administrative arm responsible for team staffing, education, and implementation; and a quality improvement arm to assess effectiveness of the RRS and identify underlying quality of care issues. RRS effectiveness should be monitored by measuring mortality, cardiac arrests, and unplanned intensive care unit admissions. The authors did not endorse a specific model for the efferent limb, stating that physician-led or nurse-led models may both be appropriate depending on local circumstances. No consensus was reached on whether all hospitals should be mandated to institute an RRS.
WebM&M Case September 1, 2005
… efforts by other stakeholders are insufficient. … John Gosbee, MD, MS … Human Factors Engineering and Healthcare … … Figure. Multi-Channel Infusion Pump … JohnGosbeeW. … John W. Gosbee
WebM&M Case February 1, 2003
… help, we will hear about cases like this one again. … John Gosbee, MD, MS … Laura Lin Gosbee, MASc … Human Factors … of Radiology; 1996. … John … Laura … GosbeeGosbeeW. … Lin … John W. Gosbee … Laura Lin Gosbee