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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 - 12 of 12 Results
Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child. 2021;106:333-337.
In the second of a two-part series, using examples from newborn units, the authors present a framework for supporting practitioners in low-resource settings to improve patient safety across four areas: (1) prioritizing critical processes, (2) improving the organization of care, (3) control of risks, and (4) enhancing responses to hazardous situations.
Amalberti R, Vincent CA. BMJ Qual Saf. 2020;29:60-63.
Health care is considered a high-risk industry due to clinical, administrative, economic, and regulatory stressors. This review explores a range of approaches to managing the safety of patients in this complex environment. The authors suggest that acceptance of the inability to eliminate all risk, focus on known problems, and engagement of all managerial levels is required to improve reliability.
Vincent CA, Carthey J, Macrae C, et al. Implementation Science. 2017;12.
In-depth review and analysis of adverse events can both inform and detract from progress in patient safety. This commentary suggests that the early event analysis approaches have not achieved their potential. The authors describe changes needed to improve incident analysis methods, including engaging patients and families in assessments and investigating a longer time period to understand the full patient care experience.
Leotsakos A, Zheng H, Croteau R, et al. Int J Qual Health Care. 2014;26:109-16.
This commentary describes a World Health Organization effort to design and apply standardized care processes to address safety concerns. Three standards (surgical site identification, medication reconciliation, and concentrated injectable medicines) have been developed and implemented in multiple countries in the past 5 years.
Maurice G de S, Auroy Y, Vincent CA, et al. Qual Saf Health Care. 2010;19:327-31.
This study tracked adoption of a process-oriented safety rule and found that compliance eroded over time, with a major trigger being lack of compliance by a senior staff member. The authors provide caution about the role of policies to promote safety behaviors, particularly if such policies are not prioritized by staff as important.
Orgeas MG, Timsit JF, Soufir L, et al. Crit Care Med. 2008;36:2041-2047.
Intensive care unit (ICU) patients are vulnerable from a patient safety standpoint, with hospital-acquired infections and medication errors being particularly common examples of adverse events (AEs). This cohort study analyzed AEs in more than 3,600 ICU patients and assessed the relationship between AEs and mortality. The overall incidence of AEs was extraordinarily high, with one in three patients experiencing at least one AE. Multiple AEs, particularly hospital-acquired infections, were independently associated with mortality. While improving safety in the ICU remains a major challenge, recent research has documented remarkable successes in preventing one of the most common AEs, catheter-related bloodstream infections.
Amalberti R, Auroy Y, Berwick D, et al. Ann Intern Med. 2005;142:756-64.
This commentary builds on the notion that our health care system requires structured efforts to improve safety and reliability. The authors summarize five primary barriers: accepting limitations on maximum performance, abandoning professional autonomy, transitioning from the "mindset of craftsman to that of an equivalent actor," needing system-level arbitration to optimize safety strategies, and simplifying professional rules and regulations. Each of these barriers is discussed with thoughtful perspective on both the associated historical and current contextual factors. In comparing safety strategies with other industries, a specific health care framework is also offered, raising distinctions that pose unique challenges. The article concludes with graphic presentation of a strategic view of safety in health care and the construct for a two-tiered system in which one system achieves "ultrasafe" status while the other does not at a calculated and accepted risk.