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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 30 Results
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
… & safety … BMJ Qual Saf … Over the last decade, the Lucian Leape Institute has explored five key areas in health care to … interview , Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at …
Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017.
… Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. … American College of Healthcare Executives; ACHE; Lucian Leape Institute of the National Patient Safety …
Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015.
… and quality data remain controversial . This report by the Lucian Leape Institute of the National Patient Safety Foundation … to the free flow of information. Prior reports from the Lucian Leape Institute have addressed the role of quality and …
Leape L. Clin Orthop Relat Res. 2015;473:1568-73.
The publication of To Err Is Human spurred efforts to improve safety in health care. This commentary reviews key patient safety concepts, interventions that successfully reduced harm (e.g., the Keystone ICU project), and persistent barriers to improvement (e.g., disruptive behavior). The author offers recommendations for health care workers interested in contributing to safer care.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
… The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss … explores the role of patient engagement in safety. … NPSF Lucian Leape Institute Roundtable on Consumer Engagement in …
Schiff G, Griswold P, Ellis BR, et al. Jt Comm J Qual Patient Saf. 2014;40:91-96.
This commentary describes the partnerships and consensus efforts involved in the PROMISES Project to promote communication and support error disclosure in the ambulatory setting. The authors review a plan to disseminate and assess the impact of the initiative and its associated tools.
Austin M, D'Andrea G, Birkmeyer JD, et al. J Patient Saf. 2014;10:64-71.
Despite availability of multiple publicly reported patient safety accountability measures, a composite score for hospital safety has yet to be developed. The Leapfrog Group convened a panel of experts to develop such a score for hospitals in the United States. The group synthesized 26 distinct safety indicators into a score comprised equally of process measures (e.g., barcode medication ordering), which recognize safety efforts, and outcome measures (e.g., catheter-associated infections). The panel also weighted the metrics based on the strength of evidence, the opportunity for improvement (i.e., the variation in performance), and the impact (i.e., the potential number of patients affected). After calculating the score for all US hospitals for which data were available, they found lower scores for rural, publicly owned hospitals with a higher percentage of patients with Medicaid as their insurance.
Leape L. Front Health Serv Manage. 2012;28:3-12.
… recommend apologizing to patients. In this interview , Dr. Lucian Leape calls for institutions to establish full disclosure, … these policies can lead to fewer malpractice lawsuits. Dr. Leape emphasizes that hospital leadership must take …
Schiff G, Leape L. Acad Med. 2012;87:135-138.
Autopsy studies spanning five decades consistently show an error rate of almost 9%, implying that thousands of patients die every year due to diagnostic errors. Despite this sobering fact, a recent review found virtually no proven mechanisms for detecting or preventing errors in diagnosis. In this commentary, two experts in the patient safety field discuss the relationship between errors in the diagnostic process, missed or delayed diagnoses, and preventable adverse events, and the potential role of information technology in reducing diagnostic error risk. The authors propose a preliminary checklist for systematizing the diagnostic process for common symptoms. This commentary is based on a related article in the same issue that investigates diagnostic errors for a common medical presenting complaint.
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
… patient safety, according to this report from the Lucian Leape Institute at the National Patient Safety Foundation. … from reporting and learning from errors . … Boston, MA: Lucian Leape Institute at the National Patient Safety …
Longtin Y, Sax H, Leape L, et al. Mayo Clin Proc. 2010;85:53-62.
Engaging patients in safety efforts is required as one of the National Patient Safety Goals, and is a key component of providing patient-centered care. This review examines ways in which patients have been integrated into clinical decision-making, discusses examples of patient involvement in reducing medication errors and encouraging hand hygiene, and proposes a framework for including patients in safety efforts. Although patient engagement has significantly improved safety efforts in some circumstances, surveys have shown that patients may be reluctant to engage in safety programs if they feel they are being asked to challenge their health care providers.
Leape L. Arch Surg. 2009;144:394-8.
In this lecture delivered to the New England Surgical Society, Lucian Leape reviews the history of the movement to improve patient safety and health care quality. He discusses the role of human factors and systems thinking in analyzing and improving safety and cites the seminal Keystone ICU study as an example of the role of standardization in improving health care. Leape advocates for just culture—a balance between systems approaches and individual accountability—and urges physicians at all levels to actively participate in safety initiatives. In contrast to other observers, Leape notes that the pace of improvement in safety compares favorably with advances in clinical care. Dr. Leape discussed his remarkable career in an AHRQ WebM&M Perspective in 2006.
Weingart SN, Morway L, Brouillard D, et al. Jt Comm J Qual Patient Saf. 2009;35:206-15.
Patients are increasingly being encouraged to be proactive in ensuring their own safety, and many organizations recommend specific actions that patients should take, such as maintaining a current list of medications or asking providers to wash their hands. However, prior research has shown that many patients are not comfortable assuming an active role in their own safety. This study reveals another problem with encouraging patient involvement—the lack of a standardized set of recommendations. The investigators reviewed recommendations from 26 organizations and found wide variation in the types and utility of suggested patient actions. Development of a unified set of recommendations for patients would likely help providers and patients work together to improve safety.