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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 - 8 of 8 Results
Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;18:e1174-e1180.
Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.
Bernstein SL, Catchpole K, Kelechi TJ, et al. Jt Comm J Qual Patient Saf. 2022;48:309-318.
Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.
Layne DM, Nemeth LS, Mueller M, et al. J Nurs Manag. 2019;27:154-160.
This pre–post study sought to examine whether a task force could reduce the risk of unprofessional behaviors at an acute care center. Certain types of negative behaviors declined, but the authors suggest that additional strategies are needed to enhance safety through professionalism.
Nemeth LS, Wessell AM. J Patient Saf. 2010;6:238-43.
This study used a theoretical model for primary care practice improvement to identify strategies to address medication safety. Key solutions focused on medication reconciliation, prevention of medication errors in selected patients, and customizing electronic health record decision support tools for dosing, drug interactions, and monitoring.