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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 - 9 of 9 Results
Olin K, Klinga C, Ekstedt M, et al. BMC Health Serv Res. 2023;23:651.
The operating room is a high-risk environment involving complex tasks. This study used cognitive task analysis (CTA) to explore how anesthesia nurses and anesthesiologists manage complex everyday situations during intraoperative care processes. Findings underscore the importance of available resources, team composition, and non-technical skills (NTS) for managing complex daily work and promoting patient safety.
Hedsköld M, Sachs MA, Rosander T, et al. BMC Health Serv Res. 2021;21:48.
Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This qualitative study characterized the role of front-line ICU managers in organizing for safe care and creating a culture of safety.  
Savage C, Gaffney A, Hussain-Alkhateeb L, et al. Int J Health Care Qual. 2017;29:853-860.
This Swedish pediatric surgery team employed crew resource management training, which included checklists, communication training, and workflow redesign. The pre–post analysis showed sustained improvements in safety culture, checklist adherence, communication quality, and unplanned returns to surgery after laparoscopic appendectomy. Although this study design cannot control for secular trends, few crew resource management analyses include patient outcomes or such lengthy follow-up.
Unbeck M, Schildmeijer K, Henriksson P, et al. Patient Saf Surg. 2013;7:10.
This comparison of two different methodologies for retrospectively detecting safety events found that the methodology used in the Harvard Medical Practice Study was more accurate than that used in the Global Trigger Tool.
Stulberg JJ, Delaney CP, Neuhauser D, et al. JAMA. 2010;303:2479-85.
Public reporting of quality measures is now widely used as a means of spurring hospitals to invest in patient safety and quality improvement efforts; however, it remains unclear if reported measures truly indicate a higher quality of care. In this study of more than 400,000 patients, researchers analyzed the relationship between adherence to recommended measures to prevent postoperative surgical infections and the subsequent development of such infections. They found that infection rates decreased only when all recommended interventions were carried out; performance of individual interventions did not seem to affect infection rates. Checklists—a relatively simple tool to ensure that all recommended steps of a process are carried out for every patient—initially gained fame as a means of preventing central line infections, and have subsequently been demonstrated to reduce surgical site infections.