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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 215 Results
Davidson JE, Doran N, Petty A, et al. Am J Crit Care. 2021;30:365-374.
… Am J Crit Care … The Joint Commission implemented medication … predicted moral distress . … Davidson JE,  Doran N, Petty A, et al. Survey of nurses' experiences applying The Joint … Commission's medication management titration standards. Am J Crit Care. 2021;30(5):365-374. doi: 10.4037/ajcc2021716 …
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ Today. 2021;104:104984. doi: 10.1016/j.nedt.2021.104984. …
Wu F, Dixon-Woods M, Aveling E-L, et al. Soc Sci Med. 2021;280:114050.
… and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. doi: 10.1016/j.socscimed.2021.114050. …
Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.
Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.
Hensley NB, Koch CG, Pronovost P, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event , a multidisciplinary quality … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …
WebM&M Case August 1, 2018
… United States inconsistent with patients' goals of care? J Palliat Med. 2017;20:1400-1404. [go to PubMed] 3. Teno JM, … study. Crit Care Med. 2004;32:638-643. [go to PubMed] 8. Thornton KC, Schwarz JJ, Gross AK, et al; Project Emerge Collaborators. …
Paine LA, Holzmueller CG, Elliott R, et al. J Healthc Risk Manag. 2018;38:36-46.
… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership …
Martin G, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27:710-717.
… BMJ Qual Saf … BMJ Qual Saf … A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture . Although formal … occurred especially if the concern was based on a general feeling that something might be wrong rather than …
Basu L, Pronovost P, Molello NE, et al. Global Health. 2017;13:64.
The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.
Leslie M, Paradis E, Gropper MA, et al. Health Serv Res. 2017;52:1330-1348.
As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.
McGinty EE, Thompson DA, Pronovost P, et al. J Nerv Ment Dis. 2017;205:495-501.
… The Journal of nervous and mental disease … J Nerv Ment Dis … Patients with underlying psychiatric … with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems …
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Jt Comm J Qual Patient Saf. 2017;43:422-428.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Utilizing a systems approach to improvement in health care is important … discusses the use of a tool that blends strategy, project monitoring, and process measurement to inform …