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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 - 20 of 80 Results
Michelson KA, McGarghan FLE, Patterson EE, et al. Diagnosis (Berl). 2023;10:183-186.
Delayed diagnosis of appendicitis can lead to serious patient harm. This study of 7,452 pediatric patients with appendicitis found that delayed diagnosis occurred in 1.4% of cases and increased clinician use of blood tests decreased the likelihood of delayed diagnosis.
Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;25:3215-3224.
Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.  
Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.
Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.
Patterson ME, Bollinger S, Coleman C, et al. Res Social Adm Pharm. 2022;18:2830-2836.
… discrepancy data from four long-term care facilities over a 9-month period and found that nearly 41% of newly admitted … for residents with respiratory conditions or pain. … Patterson ME,  Bollinger S, Coleman C, et al. Medication … discrepancy rates and sources upon nursing home intake: a prospective study. Res Social Adm Pharm. …
Ren DM, Abrams A, Banigan M, et al. Simul Healthc. 2022;17:e45-e50.
Effective team communication is a cornerstone to ensuring safe patient care, particularly during stressful situations. To evaluate baseline team communication behavior, clinicians at this institution participated in interprofessional video-recorded simulations of a code response and debriefing, followed by standardized evaluations by external reviewers. Evaluations indicate variable performance on different team communication behaviors (highest for escalating care and thinking out loud, lowest for verbally establishing leadership). The authors suggest that assessing baseline communication behaviors can guide future interventions to promote and improve quality and patient safety.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.
… , the authors used human factors engineering to develop a classification system to organize, prioritize, and … alarm sounds in order to reduce nurse response times. … Patterson ES, Rayo MF, Edworthy JR, et al. Applying human … engineering to address the telemetry alarm problem in a large medical center. Hum Factors. Epub 2021 May 19. …
Bentley SK, McNamara S, Meguerdichian MJ, et al. Adv Simul (Lond). 2021;6:9.
… Adv Simul (Lond) … Debriefing is a communication strategy for teams to improve patient safety … processes. The authors developed and pilot-tested a debriefing tool to broaden the traditional focus of … SK, McNamara S, Meguerdichian M, et al. Debrief it all: a tool for inclusion of Safety II. Adv Simul (Lond). …
Carayon P, Hoonakker P, Hundt AS, et al. BMJ Qual Saf. 2020;29:329-340.
… whether integrating human factors engineering into a clinical decision support system can improve the diagnosis … clinical decision support for diagnostic decision-making: a scenario-based simulation study [published online ahead of …
Patterson S, Schmajuk G, Evans M, et al. Jt Comm J Qual Patient Saf. 2019;45:348-357.
This retrospective cohort study sought to determine whether screening for tuberculosis and hepatitis B and C was consistently performed prior to initiating immunosuppressive medications. About a quarter of patients were appropriately screened for all three infections before starting these high-risk medications, demonstrating the need for safety protocols regarding provision of immunosuppressive medication.
Perspective on Safety May 1, 2019
… medical services care can occur anywhere—the roadside, in a home, or in public settings—with threats to safety that are … identifies and quantifies threats to safety. … P. Daniel Patterson, PhD … Associate Professor Department of Emergency … [go to PubMed] 5. Patterson PD, Weaver MD, Hostler D. EMS provider wellness. In: Cone DC, Brice JH, Delbridge …
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2021;17:e335-e342.
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.

Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.

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Bajaj K, Minors A, Walker K, et al. Simul Healthc. 2018;13:221-224.
Frontline simulations offer valuable opportunities to explore system issues, process weaknesses, and teamwork skills. This article discusses risks associated with in situ simulations and describes how to determine when simulations should be canceled, postponed, or relocated to ensure safety.
Bell SK, Folcarelli P, Fossa A, et al. J Patient Saf. 2018;17:e791-e799.
… the health care system. Engaging patients in their care is a recommended strategy to improve ambulatory safety and is the focus of a recent AHRQ toolkit . The OpenNotes initiative —in which … with primary care providers. Although hindered by a low response rate, this study provides some support for the …
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.

Patterson PD, ed. Prehosp Emerg Care. 2018;22(suppl 1):1-118.

… Health care worker fatigue is a persistent threat to patient safety. Articles in this special issue cover the results of a National Highway Traffic Safety Administration program to … in shift workers , with a focus on EMS providers. … Patterson PD, ed. Prehosp Emerg Care. 2018;22(suppl 1):1-118. …