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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 - 16 of 16 Results
Larson LA, Finley JL, Gross TL, et al. Jt Comm J Qual Patient Saf. 2019;45:74-80.
Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.

Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.

Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology. The reviews highlight systems science, collaboration, leadership models, and patient experience as important to moving safety innovation forward in this specialty.
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, the role of patients in diagnostic error reduction, and diagnostic process improvement activities implemented in various health care facilities.
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14.
… and the culture to support them. … Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14. … SC … C. … E. … Wallace … Mamrol … Finley … SC Wallace … C. Mamrol … E. …

Malekzadeh S, ed. Otolaryngol Clin North Am. 2017;50(5):xv-xviii, 875-1036.

This special issue highlights areas in otolaryngology where simulation is being used to develop multidisciplinary team-based approaches to care and education. Topics covered include the use of simulation for system improvement, the value of debriefing, and the economics of simulation.
Marella WM, Sparnon E, Finley E. J Patient Saf. 2014;13:31-36.
Voluntary error reporting systems are an important part of safety improvement programs, but difficulty in analyzing error reports has limited their utility. This study described the development of a machine learning algorithm to analyze free-text data in incident reports. The algorithm proved to be accurate in classifying events when compared to manual review.
Twycross A, Forgeron P, Chorne J, et al. J Child Health Care. 2016;20:537-541.
This commentary examines the progress in the past 5 years regarding establishing poorly managed pain in pediatric patients as an adverse event. The authors recommend using trigger tools and other surveillance methods to track and report on outcomes associated with pain management.

Su L, Fernandez R, Grand J, et al, eds. Curr Probl Pediatr Adolesc Health Care. 2015;45:365-394.

… . 2015;45:365-394. … MJ … SH … L. … R. … JA … MC … M. … ES … Waller … Parker … Su … Fernandez … Grand … Ottolini … Patterson … Deutsch … MJ Waller … SH Parker … L. Su … R. Fernandez … JA Grand … MC Ottolini … M. Patterson … ES Deutsch

Surgery. 2015;158:1395-1440.

Simulation training is widely accepted as a method to enhance operative techniques and nontechnical behaviors. Articles in this special issue cover topics in surgical education related to teamwork skills, simulation training, and error analysis as a way to assess performance.

Jacobs BR, Coppes MJ, eds. Pediatr Clin North Am. 2012;59(6):1233-1388.

… … PJ … JK … PG … JM … G. … CP … S. … S. … A. … D. … M. … ES … V. … DR … EH … MN … TP … JS … TT … A. … K. … J. … R. … … … Griswold … Ponnuru … Nishisaki … Szyld … Davenport … Deutsch … Nadkarni … Neuspiel … Stubbs … Flack … Gross … Reid … … S. Ponnuru … A. Nishisaki … D. Szyld … M. Davenport … ES Deutsch … V. Nadkarni … DR Neuspiel … EH Stubbs … MN Flack …
Marella WM, Finley E, Thomas AD, et al. J Patient Saf. 2008;3.
Patients are increasingly being asked to assume a role in ensuring their own safety. Both AHRQ's "20 Tips to Help Prevent Medical Errors" and the Joint Commission's "Speak Up" program to ensure surgical safety recommend that patients engage in specific safety practices, such as maintaining a list of their medications and asking health care workers if they have washed their hands. This survey assessed the willingness of patients to carry out these practices. Patients were much less likely to engage in behaviors that required them to challenge providers (such as checking for handwashing compliance) than less confrontational practices (such as following up on test results). The study's findings are similar to a prior AHRQ-funded study of patients recently discharged from the hospital.
Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-403, discussion 403-5.
This study examined instances of wrong-site surgery reported to authorities in Pennsylvania and sought to determine factors contributing to the error.