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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 24 Results
Henriksen K, Rodrick D, Grace EN, et al. J Patient Saf. 2021;17:e1685-e1690.
Applying systems engineering strategies from problem analysis through postimplementation evaluation can lead to solutions grounded in actual practice and learning for individuals, teams, and organizations. This commentary discusses the Agency for Healthcare Research and Quality patient safety learning laboratories initiative. The authors, who serve as program officers and oversee the grants, review lessons learned through experiences of grantees.

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

… North Am . 2019;52:1-194. … Chang CWD; Robinson TL Jr … K. … EM … CL … CA … S. … W. … RJ … KR … JR … V. … DW … BA … TS … MJ … SN … ME … SS … MJ … EK … MS … ES … MD … KR … S. … IN … T. … EL … CH … B. … RA … VK … ST … ER … … … Chandrasekhar … Brenner … Shuman … Kokoska … Deutsch … Patterson … Jatana … Chao … Jacobs … Litovitz … McKean … …
Joseph A, Henriksen K, Malone E. Health Aff (Millwood). 2018;37:1884-1891.
The built environment influences the safety and effectiveness of care delivery. This narrative review examines how care facility design can reduce health care–associated infections, falls, and medication errors. The authors provide suggestions regarding a range of facility design strategies and discuss how accreditation, funding, and policy organizations can support design projects as improvement efforts.

Health Aff (Millwood). 2018;37(11):1723-1908.

… … Van Niel M … LH … DM … H. … JP … OF … MD … DW … H. … R. … WR … L. … LR … AK … AB … R. … SJ … AA … … … M. … J. … D. … M. … D. … G. … M. … M. … A. … H. … C. … K. … D. … T. … EK … W. … J. … AW … R. … TH … MM … WM … SK … … … Menon … Hallisy … Southwick … Sarkar … Royse … Joseph … Henriksen … Malone … Jost … Kachalia … Sands … Dodson … …
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. JAMA Intern Med. 2018;178:375-382.
Preventable harm is common during and after hospital discharge. Pharmacist-delivered medication reconciliation has been proposed as a strategy to reduce adverse medication events and readmissions. Investigators conducted a three-arm randomized controlled trial comparing the effect of pharmacist-delivered medication reviews, motivational interviews, and postdischarge follow-up with nursing homes, primary care providers, and pharmacies (extended intervention); simple inpatient medication reconciliation (basic intervention); and usual care (no intervention) on outcomes for medically complex patients. The extended intervention reduced hospital readmissions and emergency department visits within 180 days of discharge while the basic intervention did not. This trial was large, robustly conducted, and demonstrated a durable improvement in safety for patients at increased readmission risk. A previous Annual Perspective explored tools for safer transitions of care.
Henriksen K, Rodrick D, Grace EN, et al. Acad Med. 2018;93:705-708.
Simulation training has been increasingly adopted as a valuable teaching tool. This editorial offers insights from program officers at the Agency for Healthcare Research and Quality regarding questions they consider when deciding on simulation projects to fund. The authors encourage research that could help to formalize the evidence base of this promising learning modality.
Henriksen K, Dymek C, Harrison MI, et al. Diagnosis (Berl). 2017;4:57-66.
… organizational factors that contribute to the problem. … Henriksen K, Dymek C, Harrison MI, Brady JP, Arnold SB. Diagnosis(Berl). 2017;4:57–66. … K. … C. … MI … JP … SB … Henriksen … Dymek … Harrison … Brady …

Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.

… H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72. … H. … K. … J. … PL … JE … ML … DE … KM … DO … RL … G. … KS … CL … O. … GD … P. … G. … S. … L. … R. … Singh … Henriksen … Brady … Epner … Gans … Graber … Newman-Toker … … … Singhal … Mamede … Zwaan … El-Kareh … H. Singh … K. Henriksen … J. Brady … PL Epner … JE Gans … ML Graber … DE …

BMJ Qual Saf. 2013;22(6):449-519.

… … ST … N. … A. … S. … S. … R. … C. … L. … L. … L. … CJ … MD … GL … RA … T. … RL … AP … J. … J. … L. … J. … MA … C. … AJ … JE … N. … L. … K. … B. … S. … H. … R. … P. … DS … EH … A. … RA … Salas … … … Vincent … Meurling … Hedman … Felländer-Tsai … Wallin … Patterson … Geis … Falcone … Lemaster … Wears … McRobert … …

Salas E, Rosen MA, eds. BMJ Qual Saf. 2013;22(5):369-448.  

… … KJ … AM … R. … R. … D. … M. … M. … J. … W. … N. … V. … K. … S. … DM … JA … M. … TA … GT … R. … SW … CA … AH … SN … … … M. … S. … D. … E. … CR … D. … L. … K. … D. … D. … B. … MD … GL … T. … RL … L. … C. … S. … S. … Salas … Rosen … Jones … … Hammer … Vorvick … Blondon … Schaad … Liner … Zierler … Patterson … Geis … Lemaster … Wears … Thomas … Galla … Lane … …
Graber ML, Kissam S, Payne VL, et al. BMJ Qual Saf. 2012;21:535-557.
Cognitive errors by individual physicians are at the root of most diagnostic errors, combining with system failures to result in preventable patient harm. Despite a rich body of literature exploring cognitive biases that contribute to misdiagnosis, few interventions to address this problem have been formally tested. This review identified 141 articles containing 3 approaches to prevent cognitive errors: improving knowledge or experience (such as using simulation training), improving clinical decision-making skills (through metacognition and reflection), and providing cognitive assistance (such as clinical decision support). However, most of the proposed interventions have not been formally tested, and even fewer have evaluated interventions outside of training settings. This group of authors also recently published a review of system interventions to prevent diagnostic errors.
Singh H, Graber ML, Kissam SM, et al. BMJ Qual Saf. 2012;21:160-170.
Diagnostic errors have been termed the next frontier in patient safety, as these errors are quite common but have not yet been targeted outside of training programs. Diagnostic errors may be caused by individual or system-level problems, and this narrative review sought to develop a taxonomy of diagnostic error dimensions and identify approaches to addressing system-level causes. The authors identified five domains: provider–patient interaction (e.g., missing important symptoms); diagnostic testing (e.g., overuse or underuse of tests); follow-up (e.g., failure to act on abnormal test results); referrals (e.g., poor communication between providers); and patient-related issues. The investigators found that few of the interventions proposed to address these issues have been formally tested, leaving clinicians with little evidence to guide approaches to minimizing diagnostic error.
WebM&M Case June 1, 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.

Qual Saf Health Care. 2010;19(suppl 3):i1-i79.  

This special issue contains articles discussing human factors and ergonomics in health care simulation, information technology use, hospitals, and home care to reveal opportunities for safety improvement.
Henriksen K, Joseph A, Zayas-Cabán T. J Patient Saf. 2009;5:229-236.
This article introduces a five-tier conceptual framework recognizing both active and latent human factors issues in home health care delivery. The authors explain how the interdependencies among those elements can help inform policies to support safety for home-based patients.

Jt Comm J Qual Saf. 2007;33(11 supp):s2-s84.

 

… Work Hours Health and Safety Group; Chou S-S … MI … K. … RG … SW … LK … NT … JM … CA … CP … SP … K. … PW … B. … MJ … D. … S. … BL … CM … Harrison … Henriksen … Hughes … Lockley … Barger … Ayas … Rothschild … …