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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 - 4 of 4 Results
Smith M, Vaughan Sarrazin M, Wang X, et al. J Am Geriatr Soc. 2022;70:1314-1324.
The COVID-19 pandemic disrupted healthcare delivery and contributed to delays in care. Based on a retrospective matched cohort of Medicare patients, this study explored the impact of the COVID-19 pandemic on patients who may be at risk for missed or delayed care. Researchers found that patients with four or more indicators for risk of missed or delayed care (e.g., chronic conditions, frailty, disability affecting use of telehealth) had higher mortality and lower rates of healthcare utilization, including primary care visits.
Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.
Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.
Pandhi N, Schumacher J, Flynn KE, et al. Health Expect. 2008;11:400-8.
Discontinuity is an unfortunate but inevitable reality of medical care, as no clinician can be available around the clock. This study surveyed geriatric patients to examine patients' perceptions of discontinuity in the outpatient setting. Although a relatively small proportion of patients reported that they would feel unsafe if seeing someone other than their primary physician, those who did report concerns tended to have more complex medical problems. This feeling may be well founded, as a recent study documented that communication between providers caring for the same patient is often poor. The safety effects of discontinuity have been most studied in the hospital, and strategies have been developed to improve the transmission of information between inpatient providers.
Zhan C, Smith M, Stryer D. Med Care. 2006;44:182-186.
This Agency for Healthcare Research and Quality (AHRQ)–sponsored study looked at the incidence of accidental iatrogenic pneumothorax (AIP) in patients who underwent certain procedures. They found that AIP occurred most frequently after thoracentesis, but also during other procedures.