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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 29 Results
MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.
Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.
Lusk C, Catchpole K, Neyens DM, et al. Appl Ergon. 2022;104:103831.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.
Hickey EJ, Halvorsen F, Laussen PC, et al. J Thorac Cardiovasc Surg. 2017;155.
Aviation safety relies on systems improvement rather than individual blame to understand and mitigate failure. This commentary applies principles key to that philosophy from commercial aviation to medicine. The authors highlight vigilance, team performance, and nontechnical skill development as strategies to improve reliability in critical care and surgery.
WebM&M Case August 1, 2017
… The patient died shortly thereafter. … The Commentary … by Ken Catchpole, PhD … In simple risk management terms, most … Charleston, SC … References … 1. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United …
Waterson P, Catchpole K. BMJ Qual Saf. 2016;25:480-4.
Despite the interest in integrating human factors engineering concepts into patient safety improvement strategies, barriers have hindered progress. This commentary explores the evidence around human factors engineering in health care to determine how to enhance the application of these concepts, such as through overlapping attention to work design, performance, and culture.
Catchpole K, Russ S. BMJ Qual Saf. 2015;24:545-9.
Checklists, while popularly considered to address safety issues, can be difficult to use reliably. Spotlighting the complexities around designing and implementing checklists to augment health care safety, this commentary relates the differences between medical and aviation checklists to underscore the need to consider sociocultural elements to ensure the success of this safety intervention.
Hignett S, Jones EL, Miller D, et al. BMJ Qual Saf. 2015;24:250-254.
Human factors engineering and quality improvement each offer promising strategies for designing patient safety interventions. This commentary discusses the value of cross-training individuals in elements of both disciplines to encourage integrated research, education, and professional development opportunities.
Morgan L, Pickering S, Hadi M, et al. BMJ Qual Saf. 2015;24:111-9.
An intervention that combined teamwork training with efforts to standardize certain operative procedures resulted in increased adherence to the World Health Organization safe surgery checklist and improved communication within the operating room. No effect was found on clinical outcomes, but the study was likely too small to detect such an impact.
Catchpole K, Ley EJ, Wiegmann D, et al. JAMA Surg. 2014;149:962-8.
Human factors analysis led to five system changes in trauma care: standardizing equipment storage, incorporating medical transport packs, using whiteboards, conducting pretrauma briefings, and performing teamwork training. Implementation of improved processes led to decreased treatment time and length of hospital stay, emphasizing the importance of human factors in enhancing safety and outcomes.
Robertson ER, Morgan L, Bird S, et al. BMJ Qual Saf. 2014;23:600-7.
… to create safer handoffs, this systematic review found a lack of reliable strategies to improve clinical handoff … The authors of this review call for establishing a common taxonomy to better classify handoffs, improvement … Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview . …
Hignett S, Carayon P, Buckle P, et al. Ergonomics. 2013;56:1491-503.
This commentary highlights challenges and potential risks around implementing human factors engineering approaches to improve patient safety and recommends areas of research to advance the understanding and reliability of these concepts.
Catchpole K, Gangi A, Blocker RC, et al. J Surg Res. 2013;184:586-91.
… The Journal of surgical research … J Surg Res … Higher acuity trauma patients were more likely … of patients from the ED to other hospital areas is a relatively understudied area of patient safety. …