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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 24 Results
Klasen JM, Beck J, Randall CL, et al. Acad Pediatr. 2023;23:489-496.
As part of clinical learning, residents and trainees are sometimes allowed to make supervised mistakes when patient safety is not at risk. In this study, pediatric hospitalists describe potential benefits and risks of allowing failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen. Consistent with previous research, patient, trainee, team, and institutional factors were identified. Additionally, caregiver/parent factors were noted.
Klasen JM, Teunissen PW, Driessen E, et al. Med Educ. 2023;57:430-439.
Learning to recover after a medical error is an important component of medical training. This qualitative study, which included postgraduate trainees from Europe and Canada, concluded that failure represents a valuable learning opportunity, but noted the importance of perceived intentions if trainees judge that their supervisors have allowed them to fail.
Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2022;44:196-205.
Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.
Klasen JM, Driessen E, Teunissen PW, et al. BMJ Qual Saf. 2020;29:727-734.
This qualitative study explored physicians experience allowing for failure for education purposes in clinical training. This study found that error permission (allowing errors to arise naturally and not preventing them) was a common strategy, particularly in procedures, medication dosing, communication, and patient management. Allowing supervised failure was perceived to be an important element of trainee development and was not considered to be a threat to patient safety.
Ott M, Schwartz A, Goldszmidt M, et al. Med Educ. 2018;52:851-860.
This observation and interview study examined instances of surgical trainees hesitating in the operating room. Both trainees and attending physicians interpreted hesitation as incompetence. The authors suggest that this interpretation of hesitation does not support progressive autonomy for trainees and must be addressed in order to promote surgical safety.
Mitchell B, Cristancho S, Nyhof BB, et al. BMJ Qual Saf. 2017;26:837-844.
Checklists have been heralded as an important tool to improve health care safety. This review examined whether the science supports that recognition. Numerous studies have been published, but the literature base hasn't been developed to fully understand the complexities of surgical checklist implementation programs.
Parshuram CS, Amaral ACKB, Ferguson ND, et al. CMAJ. 2015;187:321-9.
This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.
Gardezi F, Lingard LA, Espin S, et al. J Adv Nurs. 2009;65:1390-1399.
… J Adv Nurs … Communication failures are a known problem in operating rooms, with past studies … as potential solutions. Interprofessional conflict can be a mediating factor in such failures, and this ethnographic … to describe what the authors refer to as “silences” as a root cause of such conflict. Based on observations of …