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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 - 19 of 19 Results
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Frush K, Chamness C, Olson B, et al. Jt Comm J Qual Patient Saf. 2018;44:389-400.
Improving safety culture is an organizational challenge. This quality improvement study describes a partnership in which a large privately owned group of hospitals, postacute facilities, and outpatient clinics partnered with an academic health system to enhance safety culture and metrics. The program included an assessment of the quality at each site followed by an individual improvement plan. Each site embarked on a multimodal intervention that included leadership engagement, team training, audit and feedback, and traditional quality improvement strategies such as Plan–Do–Study–Act cycles. The authors report significant improvements across measures of patient safety such as health care–associated infections and readmissions.
Benjamin L, Frush K, Shaw KN, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.
Johnson DP, Zimmerman K, Staples B, et al. Hosp Pediatr. 2015;5:154-9.
Handoff improvement is a national patient safety priority, and residency programs are required to provide formal training in signouts. In this study, a simulation-based educational intervention for teaching handoffs to pediatric residents did not result in enhanced perception of handoff quality or improvement in clinical outcomes.
Gupta RT, Sexton B, Milne J, et al. AJR Am J Roentgenol. 2015;204:105-110.
This pre-post study found improvements in safety culture, as measured by the Safety Attitudes Questionnaire, following the implementation of AHRQ's TeamSTEPPS tools. These findings add to the body of research supporting teamwork training as a way to enhance safety.
Schwendimann R, Milne J, Frush K, et al. Am J Med Qual. 2013;28:414-21.
Executive walkrounds are widely used for improving safety culture, but their effect on specific patient safety attitudes and outcomes is not well established. This retrospective study found that leadership walkrounds participation was strongly associated with positive safety climates and greater risk reductions. While the application of leadership walkrounds varies widely from institution to institution, this multicenter study used a standardized strategy that included monthly hospital executive visits and scripted, open-ended questions meant to engage staff in patient safety discussions. An AHRQ WebM&M perspective discussed the importance of involving hospital leadership with safety and quality.
Turner K, Frush K, Hueckel RM, et al. J Nurs Care Qual. 2013;28:257-64.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-10.
Reviewing evidence on transitions in care, this article describes how one university health system developed a comprehensive handoff curriculum to address educational needs in the context of changes to resident duty hours.
Gaca AM, Frush DP, Hohenhaus SM, et al. Radiology. 2007;245:236-44.
This study developed a simulation model in the radiology environment and identified the need for greater resuscitation aids to treat unexpected clinical events. A past AHRQ WebM&M commentary discussed the role of simulation as a method to practice both behavioral and technical skills.
Perspective on Safety May 1, 2005
… world's preeminent academic medical centers. We asked Dr. Karen Frush, a pediatrician who became Duke's Chief Patient Safety … care depends on this type of cooperative leadership. … Karen Frush, MD … Chief Patient Safety Officer, Duke …
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...