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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 35 Results
Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;10:417-423.
Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

Santhosh L, Cornell E, Rojas JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. AHRQ Publication No. 23-0040-1-EF.

Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.
Santhosh L, Lyons PG, Rojas JC, et al. BMJ Qual Saf. 2019;28:627-634.
This mixed-methods study combined survey data from resident physicians with a comparison of process maps from three academic medical centers to assess handoffs from intensive care units to medical wards. The vast majority of survey respondents could recall at least one adverse event related to suboptimal handoff communication between these settings, and review of the process maps revealed safety gaps in existing processes.
Chacko KM, Halvorsen AJ, Swenson SL, et al. Am J Med Qual. 2018;33:405-412.
Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.
Matern LH, Farnan JM, Hirsch KW, et al. Simul Healthc. 2018;13:233-238.
Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.
Wray CM, Chaudhry S, Pincavage A, et al. JAMA. 2016;316:2273-2275.
Research suggests that standardization, dedicated space, and supervision improve resident handoffs, but less is known about how these best practices are implemented. Investigators surveyed residency program directors and found significant variation in the implementation of recommended handoff practices and educational strategies.
Martin SK, Tulla K, Meltzer DO, et al. J Grad Med Educ. 2017;9:706-713.
This survey study examined remote electronic health record use by attending physicians for resident supervision. Nearly all respondents reported accessing the electronic health record remotely. Of these, 92% reported discovering clinically relevant information that the residents had not conveyed to them. The authors conclude that this "backstage" supervision requires further study to identify best practices for safety and education.
WebM&M Case June 1, 2017
… the radiograph had been performed. … The Commentary … by Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD … In this … 1952;21:663-676. [go to PubMed] 3. Menger R, Telford G, Kim P, et al. Complications following thoracic trauma …
Myers JS, Tess A, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.
It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.
Pincavage A, Donnelly MJ, Young JQ, et al. Jt Comm J Qual Patient Saf. 2017;43:71-79.
Year-end handoffs in residency training settings are a known patient safety risk. This narrative review found that several practices can enhance the safety of year-end transitions, including standardizing written and verbal signout for high-risk patients and enhancing attending-level supervision.
WebM&M Case April 1, 2016
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.
Farnan JM, Gaffney S, Poston JT, et al. BMJ Qual Saf. 2016;25:153-8.
This simulation study challenged medical students to identify patient safety hazards in a hospital room. Students demonstrated a wide range of accuracy in identifying hazards, with fall risk most likely and pressure ulcer risk least likely to be identified. This finding shows the utility of simulation in patient safety education.
Tanksley AL, Wolfson RK, Arora V. JAMA. 2016;315:603-4.
Clinicians often feel pressured to work while sick or fatigued because of cultural and system factors, including fear of failing colleagues or patients. Exploring findings from a previous study on presenteeism, this commentary spotlights the need for health care organizations to discourage clinicians from working while ill which poses risks to patients. The authors recommend strategies and policies to address this problem, including promoting professionalism that conveys physicians must be healthy enough to provide patient care.
Weinstein DF, Arora V, Drolet BC, et al. New England Journal of Medicine. 2013;369.
… by Dr. Debra Weinstein, the discussion featured Dr. Vineet Arora, Dr. Eileen Reynolds, and surgical resident Dr. Brian … of their overnight experiences. A recent AHRQ WebM&M perspective and interview also discussed the potential …
Pincavage A, Lee WW, Beiting KJ, et al. J Gen Intern Med. 2013;28:999-1007.
The academic year-end transfer of primary care patients from graduating residents to their successors can pose risks to patients. This survey of patients within an academic primary care practice identifies the concerns patients have with the transfer process and the barriers in care they encounter as a result.
Greenstein EA, Arora V, Staisiunas PG, et al. BMJ Qual Saf. 2013;22:203-9.
Although much research on effective handoffs has emphasized the responsibility of the sender (the clinician transmitting information), this study evaluated the behavior of clinicians receiving handoffs and found that most clinicians did not engage in active listening behaviors that could improve the quality of information transmission.