The PSNet Collection

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.

Patient and family engagement: a survey of US hospital practices.

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Herrin J, Harris KG, Kenward K, et al. BMJ Qual Saf. 2016;25:182-9.

This survey of acute care hospitals found significant variation for patient and family engagement activities. Most hospitals reported unrestricted visitor access, nearly two-thirds had formal error disclosure policies, and less than half had a patient advisory council. These findings demonstrate the gap between patient engagement recommendations and current hospital practice.

Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in 2012.

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DesRoches CM, Charles D, Furukawa MF, et al. Health Aff (Millwood). 2013;32:1478-85.

Despite considerable federal financial incentives intended to promote electronic health record (EHR) use, as of 2012 only 42.2% of hospitals in the United States had implemented a system that met federal "meaningful use" criteria (which include use of computerized provider order entry with decision support). Rural and nonteaching hospitals were less likely to have implemented an EHR compared with larger urban hospitals.

The Soil, Not the Seed: The Real Problem with Root Cause Analysis

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Perspective on Safety July 1, 2008

Throughout most of his life, 19th century French chemist Louis Pasteur insisted that germs were the cause of disease, not the body. It wasn't until Pasteur was nearing the end of his life that he came to believe just the opposite. After reaching this conclusion, he declined treatment for potentially curable pneumonia, reportedly saying, "It is the soil, not the seed."(1) In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment.

Getting the board on board: engaging hospital boards in quality and patient safety.

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Joshi MS, Hines S. Jt Comm J Qual Patient Saf. 2006;32:179-87.

… low levels of knowledge with respect to quality, a disconnect between CEO perceptions of how well board chairs … performance on quality measures. The authors provide a series of strategic recommendations to close the reported … mechanisms for planning with incentives and maintaining a patient-centered focus. …

A comprehensive grassroots model for statewide safety improvement.

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Joshi MS, Kazandjian VA, Martin P, et al. Jt Comm J Qual Patient Saf. 2005;31:671-677.

… key initiatives of the Maryland Patient Safety Center, a 2005 Eisenberg award winner, and propose that their approach can be used as a model for patient safety programs in other states. …

Understanding safer practices in health care: a prologue for the role of indicators.

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Kazandjian VA, Wicker K, Ogunbo S, et al. J Eval Clin Pract. 2005;11:161-70.

The authors assessed the usefulness of the AHRQ Quality Indicator Project to measure medical error. The findings suggest some validity to using the quality indicator data to map safety issues, but further study is needed.

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