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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 - 8 of 8 Results
Schwappach DLB, Pfeiffer Y. Patient Saf Surg. 2023;17:15.
Retained surgical items (RSIs) can lead to serious patient harm. Survey findings from 21 clinicians and stakeholders in Switzerland emphasized the importance of addressing production pressures, encouraging a culture of safety and teamwork, and implementation of effective counting procedures to reduce the incidence of retained surgical items.
Pfeiffer Y, Atkinson A, Maag J, et al. J Patient Saf. 2023;19:264-270.
Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.
Goekcimen K, Schwendimann R, Pfeiffer Y, et al. J Patient Saf. 2023;19:e1-e8.
Incident reporting systems are common tools to detect patient safety hazards. This systematic review synthesized evidence from 41 studies using incident reporting system data to identify and characterize critical incidents. Medication-related incidents and incidents due to “active failures” were the most commonly reported events. The authors observe that only one in three studies reported on corrective actions due to the incidents, highlighting the need to emphasize the importance of learning from errors.
Pfeiffer Y, Zimmermann C, Schwappach DLB. J Patient Saf. 2020;Publish Ahead of Print.
This study examined patient safety issues stemming from health information technology (HIT)-related information management hazards. The authors identified eleven thematic groups describing such hazards occurring at a systemic level, such as fragmentation of patient information, “information islands” (e.g., nurses and physicians have separate information sets despite the same HIT system), and inadequate information structures (e.g., no drug interaction warning integrated in the chemotherapy prescribing tool).
Pfeiffer Y, Zimmermann C, Schwappach DLB. BMJ Qual Saf. 2020;29:536-540.
Double checking is one strategy for detecting and preventing medication errors; however, its effectiveness is unclear. This editorial presents a framework intended to further research and clinical practice by defining and classifying checking procedures and differentiating them from other medication-related safety behaviors.
Schwappach DLB, Taxis K, Pfeiffer Y. BMC Health Serv Res. 2018;18:123.
Medication errors are common and particularly dangerous when they involve chemotherapy. Investigators surveyed Swiss oncology nurses about double-checking medications before administration, a widely practiced strategy. Most nurses endorsed double-checking as an effective safety tool, despite the fact that double-checking promotes workflow interruptions, is labor intensive, and is less effective than automated barcode scanning.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.