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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 37 Results
Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.
Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.
Moffatt-Bruce SD, Nguyen MC, Steinberg B, et al. Clin Obstet Gynecol. 2019;62:432-443.
Burnout among health care professionals is widely understood as an organizational problem in health care. This study describes a longitudinal, institutional program to reduce burnout and improve provider wellness at an academic medical center. A longstanding crew resource management intervention led to a decreasing number of patient safety events, which the authors connect to culture change. The program also included provision of mindfulness training for trainees and faculty to promote resilience. They measured self-reported burnout at prespecified intervals and documented improvement over time. The authors conclude that the combination of team training and individual mindfulness education can reduce burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed interventions to address burnout among clinicians.
Patterson ES, Sillars DM, Staggers N, et al. Jt Comm J Qual Patient Saf. 2017;43:375-385.
Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Ann Thorac Surg. 2017;103:1693-1699.
Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Surgery. 2016;160:858-868.
The AHRQ Patient Safety Indicators (PSIs) rely on hospital administrative data to screen for patient safety problems. This study used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure) in identifying clinically significant patient safety events and found a positive predictive value of 38.3%. The authors argue that PSI 11 should not be used as a measure for hospital performance.
Moffatt-Bruce SD, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;102:358-62.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.
Hertig JB, Hultgren KE, Weber RJ. Hosp Pharm. 2016;51:338-44.
Frontline and organizational leadership are key to implementing and sustaining safety improvement efforts. This commentary describes management principles that can prepare individuals as leaders in implementing a medication safety program, including skills in team-building, communication, tracking project progress, and encouraging innovation.
Storey MA, Weber RJ, Besco K, et al. Nutr Clin Pract. 2016;31:211-7.
Parenteral nutrition (PN) can result in patient harm if prepared or administered improperly. Recent shortages of PN ingredients have forced pharmacies to deviate from guidelines for safe PN preparation, but this study found that the incidence of errors has not increased.
Krzan KD, Merandi J, Morvay S, et al. Am J Health Syst Pharm. 2015;72:563-7.
The term "second victims" was coined to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. A structured program to provide immediate support to clinicians affected by medical errors was well received by the pharmacy staff at a pediatric hospital.
Rayo MF, Moffatt-Bruce SD. BMJ Qual Saf. 2015;24:282-6.
Alarm fatigue has generated substantial attention as a patient safety hazard. Exploring risks associated with alarm fatigue and factors that contribute to it, this review recommends that interventions and design alternatives be considered to enhance clinician response to alerts.
Moffatt-Bruce SD, Denlinger CE, Sade RM. Ann Thorac Surg. 2014;98:396-401.
A general consensus exists that physicians should disclose their own errors, but the responsibility of reporting colleagues' errors to patients and their families is not as clearly understood. This commentary uses a case example to illustrate perspectives for both sides of the debate surrounding the ethics of this issue.