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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 85 Results
Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.
Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.
Grailey K, Lound A, Murray E, et al. PLoS One. 2023;18:e0286796.
Effective teamwork is critical in healthcare settings. This qualitative study explored experiences with personality, psychological safety and perceived stressors among emergency and critical care department staff working in the United Kingdom. Findings underscore the ways in which personality traits can influence team performance.
Merchant NB, O’Neal J, Dealino-Perez C, et al. Am J Med Qual. 2022;37:504-510.
… Am J Med Qual … The goal for health care organizations to attain … but elusive . This article shares insights drawn from a Veterans’ Health system effort to support high reliability. … training, and safety culture . … Merchant NB, O'Neal J, Dealino-Perez C, et al. A high-reliability organization …
Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.
… presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those … at least one risk factor for misuse. … Bloomer A, Wally M, Bailey G, et al. Balancing safety, comfort, and fall risk: an …
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
… Int J Med Inform … A range of health information technologies (e.g., computerized provider order entry) is used in patient … on patient quality or safety outcomes. … Bail K, Gibson D, Acharya P, et al. Using health information technology in …
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. J Patient Saf. 2022;18:e308-e314.
Peer support programs are increasingly used to support clinicians involved in adverse events. This evaluation found that a structured peer support program for providers involved in obstetric adverse events can effectively support providers in short periods of time (for example, 92% of participants did not need follow-up after second peer support contact) and can be initiated with limited resources.
Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.
… Jt Comm J Qual Patient Saf … The COVID-19 pandemic has exacerbated … errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning … concerns related to COVID-19. … Shen L,  Levie A, Singh H, et al. Harnessing event report data to identify diagnostic …
Grailey K, Leon-Villapalos C, Murray E, et al. BMJ Open. 2021;11:e046699.
Psychological safety enables staff to raise concerns, reduce mistakes and learn from errors. The majority of surveyed intensive care unit staff in three units within one trust in London reported feeling psychologically safe within their teams (e.g. being able to bring up problems). In a novel finding, this study identified potential negative consequences of psychological safety, including distraction and fatigue for team leaders.
Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;68:356-363.
Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.
Cicci CD, Fudzie SS, Campbell-Bright S, et al. Am J Health Syst Pharm. 2021;78:736-742.
… Am J Health Syst Pharm … When patients are admitted to the … low risk of harm.   … Cicci CD, Fudzie SS, Campbell-Bright S, et al. Accuracy and safety of medication histories … of delirious or mechanically ventilated patients. Am J Health Syst Pharm. …
Sprogis SK, Street M, Currey J, et al. Aust Crit Care. 2021;34:580-586.
Medical emergency teams (MET), also known as rapid response teams, are used to improve the identification and management of patients demonstrating signs of rapid deterioration. This study found that modifying activation criteria to trigger METs at more extreme levels of clinical deterioration were not associated with negative patient safety outcomes.
Desai S, Eappen S, Murray K, et al. Jt Comm J Qual Patient Saf. 2020;46:715-714.
… Jt Comm J Qual Patient Saf … This article describes the implementation of a new system for identifying, communicating, and resolving … reporting systems and daily huddles . … Desai S, Eappen S, Murray K, et al. Rapid-cycle improvement during the COVID-19 …
Gilleland J, Bayfield D, Bayliss A, et al. BMJ Open Qual. 2019;8:e000763.
… time to treatment is less common. The article discusses a consensus workshop, the goal of which was to develop the … despite use of usually effective treatment. … Gilleland J, Bayfield D, Bayliss A, et al. BMJ Open Qual. 2019;8(4):e000763. doi: …
Archer S, Thibaut BI, Dewa LH, et al. J Psychiatr Ment Health Nurs. 2019;27:211-223.
Researchers conducted focus groups in this qualitative study of staff in mental healthcare settings and assessed the barriers and facilitators to incident reporting. The authors identified unique challenges to incident reporting in mental health, including the incidence of violence and aggressive behavior. Participants often underreported violent or aggressive events because they attributed the behavior to the patient’s diagnosis, and cited dissatisfaction with how reported incidents were handled by police.