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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 29 Results
List JM, Russell LE, Hausmann LRM, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 10.
Unmet health-related social needs (HRSNs; e.g., housing instability, food insecurity) and healthcare disparities can place patients at increased risk for patient safety incidents and poor outcomes. This article describes how existing Veterans Health Administration (VHA) initiatives to address HRSNs and disparities are being leveraged to address new Joint Commission standards to improve health care equity.
Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2022;37:81-83.
Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Am J Obstet Gynecol. 2014;211:208-214.e1.
… Obstet Gynecol … This commentary summarizes findings from a multidisciplinary panel, convened as part of a broad-based obstetric medication safety improvement … of providing guidance on these processes and developing a systematic approach for other teams initiating similar …
Clancy CM, Berwick DM. Ann Intern Med. 2011;154:699-701.
Accompanying a consensus statement, this editorial discusses the challenges of conducting research in complex settings, and notes existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.
Clancy CM. Am J Med Qual. 2009;24:344-6.
In this commentary, AHRQ Director Carolyn Clancy discusses effective patient discharge as an important factor in patient safety. Specifically, she highlights elements of an AHRQ-funded implementation program for engaging patients along with their clinical team to enable smooth discharge.
Pronovost P, Goeschel CA, Olsen KL, et al. Health Aff (Millwood). 2009;28:w479-89.
Since the landmark IOM report on medical errors, the field of patient safety has frequently relied on the aviation industry as a source of learning to prevent accidents and harm in health care. This commentary explores these learnings further by highlighting the success of the Commercial Aviation Safety Team (CAST), a public–private enterprise voluntarily established by the aviation industry and the government in the mid-1990s. The authors, led by a pioneer in the patient safety field, propose a similar partnership in the health care community to coordinate a national agenda in improving the quality and safety of care. They call the proposed organization the Public Private Partnership to Promote Patient Safety (P5S), and provide a model for its success.
Hughes RG, Clancy CM. J Nurs Care Qual. 2009;24:1-4.
This commentary discusses the broad role of nursing in patient safety, the leadership and organizational roles they can play, and Agency for Healthcare Research and Quality’s Evidence-Based Handbook for Nurses.
Zhan C, Smith SR, Keyes MA, et al. Jt Comm J Qual Patient Saf. 2008;34:36-45.
Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.