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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 - 12 of 12 Results
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Sujan M, Habli I. BMJ Qual Saf. 2021;30:1047-1050.
This commentary discusses the use of “safety cases” to communicate the safety of a product, system or service in industry (e.g., aviation, defense, railways). Using an example of a smart infusion pump, the authors discuss how to apply this concept in healthcare to support the safe adoption of digital health innovations.
Blandford A, Dykes PC, Franklin BD, et al. Drug Saf. 2019;42:1157-1165.
Intravenous medication infusions are an important target for safety interventions. Many infused medications, such as opioids and chemotherapy, require vigilant adherence to protocol to prevent harm. Technical solutions to infusion errors such as computerized provider order entry, barcode medication administration, and smart infusion pumps have been implemented with some success. Investigators compared infusion errors in the United States, where all three technical interventions are common, to the United Kingdom, where those technical interventions are rare. Minor errors were common in each country, but only 0.8% of infusions placed patients at serious risk of harm. Although the details of errors in both countries differed in detail, rates of error and harm were similar. A WebM&M commentary described a chemotherapy infusion error that caused renal failure.
Sujan M. J Innov Health Inform. 2018;25:952.
Health information technology (IT) holds both promise and peril for clinicians and patients. To manage problems associated with health IT systems, this commentary recommends applying risk assessment and organizational learning strategies to identify and address predictable risks.
Sujan M. Reliab Eng Syst Saf. 2015;144.
This qualitative study found that despite the public outcry over care standards at Mid Staffordshire NHS Foundation trust, barriers to incident reporting persist, including lack of familiarity among frontline staff, poor feedback, fear of repercussions, and insufficient equipment and training. This suggests that novel approaches to enhancing safety and reporting culture are needed.
Sujan M, Spurgeon P, Cooke M. Reliab Eng Syst Saf. 2015;141.
According to this human factors study, handoff practices in emergency medicine vary depending on physicians' competing demands. The authors suggest that these dynamic trade-offs in which handoff practices are adjusted for specific situations actually enhance safety, in contrast to recent work promoting standardized handoff communication.