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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 - 15 of 15 Results
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26:251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.
Thomas NJ, Lynam AL, Hill A, et al. Diabetologia. 2019;62:1167-1172.
This population-based cohort study sought to determine whether patients with adult-onset type 1 diabetes are misdiagnosed. Investigators found that 21% of the patients diagnosed with type 2 diabetes after age 30 actually had type 1 diabetes. They caution clinicians to carefully consider type 1 diabetes in adults requiring insulin.
Gallagher TH, Mello MM, Sage WM, et al. Health Aff (Millwood). 2018;37:1845-1852.
Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.
Helmchen LA, Burke ME, Wojtusiak J. J Healthc Risk Manag. 2015;34:7-17.
Efforts to increase incident reporting may lead to reporting of events that do not have risk for subsequent litigation. This study demonstrated that modeling based on automated data mining of event reports could identify reports that were most likely to be associated with subsequent malpractice claims. This suggests that actions to address adverse events, such as disclosure programs, could be deployed more efficiently using an automated algorithm to detect high-risk event reports in real time.
Wu AW, McCay L, Levinson W, et al. J Patient Saf. 2017;13:43-49.
… Journal of patient safety … J Patient Saf … Based on a series of international expert meetings, this qualitative … enhanced patient and provider education to foster a blame-free safety culture , and establishment of standard … document and benchmark disclosure across institutions. In a past AHRQ WebM&M perspective , Dr. Albert Wu discussed the …
Sage WM, Gallagher TH, Armstrong S, et al. Health Aff (Millwood). 2014;33:11-9.
Communication-and-resolution programs continue to face challenges to implementation despite their demonstrated value. This commentary recommends policy adjustments for legal, payment, and peer review protection to address barriers to implementing such programs and optimize their widespread adoption.
Mello MM, Boothman RC, McDonald TB, et al. Health Aff (Millwood). 2014;33:20-29.
When a patient is a victim of an error, hospitals have traditionally followed a "deny and defend" strategy, providing limited information to the patient and family and avoiding admissions of fault—or even admission that an error occurred. This approach has long been criticized for its lack of patient-centeredness, and in response some institutions have begun to implement communication-and-response strategies that emphasize early disclosure of adverse events and proactive attempts to resolve the situation. This study reviews six institutions' experiences with two types of communication-and-response strategies: early settlement programs (in which errors are fully disclosed and an offer of compensation is made, along with investigation of safety issues) and limited reimbursement programs (which provided limited compensation to patients with concerns about their care, but explicitly exclude more severe errors). Through structured interviews with key participants, the authors identify crucial regulatory, legal, and practical issues with implementing these programs. They emphasize that such programs should be viewed as part of an effort to improve safety culture and that transparency and a blame-free approach are essential to obtaining support (especially from physicians). The complex intersection between error disclosure and malpractice is explored further in an AHRQ WebM&M perspective.
Bell SK, Delbanco T, Anderson-Shaw L, et al. Chest. 2011;140:519-526.
… bear some responsibility in most cases of errors, and a vigorous debate continues around the level of … clinician, the health care team, and the institution—as a way to balance the distinction between systems issues and personal responsibility. Using an example case of a diagnostic error , the authors discuss how collective …
Helmchen LA, Richards MR, McDonald TB. Med Care. 2010;48:955-61.
… sue if errors are disclosed promptly and completely, and a recent study from the University of Michigan provides some … one quarter of respondents would sue after learning of a medical error, patients who had confidence that their …