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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
Barlow M, Watson B, Morse K, et al. J Health Organ Manag. 2023;Epub Sep 26.
Hierarchy and expected response may inhibit someone from speaking up about a safety concern. This study used two vignettes of a speaking up situation with randomization on speaker seniority, discipline (i.e., allied staff, nurse, physician), tone (i.e., accommodating or non-accommodating), and the presence of other people in the room. All participants were more likely to respond positively to the accommodating tone, but the impact of seniority varied by receiver's discipline.
Barlow M, Watson B, Jones EW, et al. BMC Nurs. 2023;22:26.
Healthcare providers may decide to speak up or remain silent about patient safety concerns based on the expected response of the recipient. In this study, clinicians from multiple disciplines responded to two hypothetical speaking up scenarios to explore the impact of communication behavior and speaker characteristics (e.g., discipline, seniority, presence of others) on the recipient’s intended response. Each of the factors played a role in how the clinician received the message and how they would respond.
Takizawa PA, Honan L, Brissette D, et al. FASEB Bioadv. 2020;3:175-181.
The COVID-19 pandemic has led to wide-ranging changes in the health care system. This article describes one academic hospital’s experience adapting in-person team-based clinical and interprofessional training during the COVID-19 pandemic.
Kaldjian LC. Patient Educ Couns. 2021;104:989-993.
Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.
Sunkara PR, Islam T, Bose A, et al. BMJ Qual Saf. 2020;29:569-575.
This study explored the influence of structured interdisciplinary bedside rounding (SIBR) on readmissions and length of stay. Compared to the control group, the odds of 7-day readmission were lower among patients admitted to a unit with SIBR (odds ratio=0.70); the intervention did not reduce length of stay or 30-day readmissions.
Gordon JRS, Wahls TL, Carlos RC, et al. Ann Intern Med. 2009;151:21-7, W5.
This study discovered that more than half of newly identified aortic dilations on computed tomography scans were not documented by clinicians in subsequent encounters. The authors advocate for improved systems to follow up on abnormal test results.
Kaldjian LC, Jones EW, Wu BJ, et al. J Gen Intern Med. 2007;22:988-96.
Prior research has demonstrated that patients desire full disclosure of medical errors, but physicians often "choose their words carefully," failing to openly discuss errors with patients. This study surveyed faculty physicians, residents, and medical students at four academic medical centers regarding their experiences and attitudes toward disclosing errors. While nearly all physicians supported full error disclosure in theory, more than 20% admitted failing to report an error to a patient under their care. The study also explores factors associated with willingness to disclose errors.