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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 36 Results
Bagian JP, Paull DE, DeRosier JM. Surg Open Sci. 2023;16:33-36.
The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.
Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.
Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.
Lester CA, Flynn AJ, Marshall VD, et al. J Am Med Inform Assoc. 2022;29:1471-1479.
Although e-prescribing has improved the safety of medication ordering, preventable errors persist. This study analyzed product descriptions (ingredient, strength, dose form) of more than 10 million e-prescriptions. Results show a wide variety in the way drug product descriptions are entered into e-prescription programs (e.g., 707 variants for “oral tablet” such as tablet, tab, po tab). Poor standardization of terminology in e-prescription programs can lead to incorrect medication order and patient confusion.
Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Jt Comm J Qual Patient Saf. 2019;45:680-685.
Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.
Carpenter JE, Bagian JP, Snider RG, et al. J Bone Joint Surg Am. 2017;99:1604-1610.
Team training programs have become a core element of safety improvement strategies worldwide. This commentary describes how one health system implemented a training initiative that focused on communication, use of a preprocedure time-out, and briefings and debriefings to enhance the safety of surgical care. The authors discuss the impact the program had on safety culture and checklist adherence.
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.
Bagian JP. Human Factors and Ergonomics in Manufacturing & Service Industries. 2011;22.
Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.
Young-Xu Y, Neily J, Mills PD, et al. Arch Surg. 2011;146:1368-73.
A seminal study found a strong association between a teamwork training intervention and improved surgical mortality at a large group of Veterans Affairs (VA) hospitals. This analysis of data from the same study also found improvements in surgical morbidity and preventable adverse events after implementation of the VA's Medical Team Training program.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.
DeRosier JM, Stalhandske E, Bagian JP, et al. Jt Comm J Qual Improv. 2002;28:248-267, 209.
The Joint Commission Center for Transforming Healthcare aims to use rigorous quality improvement methodologies to tackle pervasive quality and safety issues. This article details the early progress of the Center's second major initiative, improving handoff communication.
Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.
Classic studies have demonstrated that operating rooms are rife with communication and teamwork problems, and suboptimal teamwork has been linked to poor postoperative patient outcomes. In this rigorously designed study, surgical teams at 74 Veterans Affairs (VA) hospitals underwent teamwork training through the VA's Medical Team Training program. The training also included implementation of preoperative and postoperative checklists. The teamwork training was associated with a striking reduction in mortality compared to other VA hospitals that had not yet implemented the program, and a dose–response effect was also evident, with continuing training resulting in further reductions in mortality. An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based evaluation of a safety intervention, and stresses that addressing teamwork and safety culture are as essential to improving safety as technical and procedural interventions such as checklists.
Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-4.
The Veterans Health Administration has pioneered implementation of several innovative safety interventions, including teamwork training (using the Medical Team Training model) for surgical and intensive care unit staff. This report on the early effects of the teamwork training initiative found positive perceptions of the impact on teamwork, communication, efficiency, and patient safety. This preliminary study also provides examples of changes in participant behavior and clinical outcomes associated with implementation of the teamwork program. Failure to report these outcomes is a common limitation of teamwork training studies, as discussed in a recent systematic review.