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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 44 Results
Arora S, Tsang F, Kekecs Z, et al. J Patient Saf. 2021;17:e1884-e1888.
An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.
WebM&M Case May 1, 2019
… the surgeon, "I think we have an unsafe situation. I can't explain her hypotension. Are you sure she isn't bleeding? … several days later. … The Commentary … Commentary by John Day and John T. Paige, MD In this case, clear … in the perioperative setting: a contemporary review. Can J Anaesth. 2017;64:128-140. [go to PubMed] 4. Guttman OT, …
Martin G, Khajuria A, Arora S, et al. J Am Med Inform Assoc. 2019;26:339-355.
This systematic review examined whether mobile technology has been shown to improve teamwork or communication in acute care settings. Few studies met methodological quality standards, but researchers conclude that mobile technology holds promise to enhance safety through improved teamwork and communication in hospital settings.
Hassen Y, Singh P, Pucher PH, et al. Surgery. 2018;163:1226-1233.
Safe surgical care requires attention to risks in the operating room and in the postoperative surgical ward. Investigators interviewed clinicians, nurses, patients, and administrators to determine the most vital components for a safe surgical ward, which included an adequate nursing skill mix and positive safety culture. A PSNet perspective described how surgical safety has evolved as a field.
Aggarwal R. JAMA Surg. 2017;152:995-996.
… JAMA surgery … JAMA Surg … Performance standards in surgical care range from those tracking technical … to hospital volume . Reviewing various ways to assess surgical skill such as video review and how nontechnical … like communication and situational awareness can affect surgical performance, this commentary highlights the …
Gardner AK, Johnston MJ, Korndorffer JR, et al. The Joint Commission Journal on Quality and Patient Safety. 2017;43.
… Joint Commission Journal on Quality and Patient Safety … Simulation has been advocated as a tactic to study team … and care activities. This review identified four key ways simulation-based techniques are used to identify factors that …
Parand A, Faiella G, Franklin BD, et al. Ergonomics. 2018;61:104-121.
Informal caregivers can make errors in administering medications to patients in home settings. This human factors analysis identified multiple vulnerabilities, including incorrect dosing, storage, timing, and failure to discontinue medications as instructed. The authors note an overall lack of support and communication for caregiver-administered medications in home and community settings.
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. The Joint Commission Journal on Quality and Patient Safety. 2017;43.
… to errors. Introductions are the first step in the surgical time-out in the World Health Organization Surgical Safety Checklist . However, this study—conducted in … other's names and may not view introductions as important for maintaining safety. …
Johnston MJ, Davis R, Arora S, et al. World J Surg. 2015;39:2207-13.
… World journal of surgery … World J Surg … This cross-sectional study at three London hospitals evaluated factors related to surgical ward patients' willingness to call for help. Although patients were more likely to call a nurse …
Arora S, Hull L, Fitzpatrick M, et al. Ann Surg. 2015;261:888-893.
This simulation study examined how residents respond to postoperative deterioration in the surgical ward. Residents improved in validated assessments of clinical performance, teamwork, and communication with patients compared to before the simulation. This work underscores the importance of simulation in patient safety education across multiple clinical settings.
Johnston MJ, Arora S, King D, et al. Surgery. 2014;155:989-94.
This interview study examined escalation of care, the process by which a patient's deteriorating clinical status is recognized and acted upon, among surgical patients. Attending surgeons, trainees, intensivists, and rapid response team members believe that protocols for escalation of care lack clarity and that there is a dearth of supervision from senior clinicians. Similar to studies of handoffs, direct conversation—either in person or via mobile phone—was deemed preferable to hospital paging systems. Participants identified communication training, explicit and clear protocols, and increased supervision as key to improving the care of deteriorating surgical patients. Accompanying editorials highlight the importance of communication and the need for a safety culture that supports multidisciplinary teams.
Johnston MJ, Arora S, Anderson O, et al. Ann Surg. 2015;261:831-838.
… training settings, the first physician point-of-contact for a patient with clinical deterioration is a junior doctor … and analysis to examine the escalation of care process on surgical wards at three London hospitals. The investigation … discussed some of the pitfalls of hierarchy and the "surgical personality." …