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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 - 18 of 18 Results
Placona AM, Rathert C. Med Care Res Rev. 2022;79:3-16.
This systematic review analyzed results of 32 studies comparing online patient reviews (OPRs) and measures of patient outcomes. While OPRs did have positive associations with patient experience, associations between OPRs and quality measures were mixed. Due to the weight that patients give OPRs, future research should focus on associations between OPRs and encounter setting, specialty, and specific quality measures.
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Tölli S, Kontio R, Partanen P, et al. Perspect Psychiatr Care. 2020;56:785-796.
This study used qualitative methods to understand the experiences of former psychiatric patients that nursing staff considered challenging and that resulted in behavior management interventions (e.g., aggression, self-harm, inappropriate sexual behavior). Interviewed patients cited various reasons for these challenging behaviors, including communication difficulties related to their psychiatric symptoms, stressful feelings such as frustration and fear, coercive nursing culture and restrictive nursing practices. Strategies for managing these behaviors are discussed, as well as core competencies for delivering care based on patients’ needs.
Sahlström M, Partanen P, Azimirad M, et al. J Nurs Manag. 2019;27:84-92.
This survey of medical inpatients at five academic medical centers in Finland aimed to elicit patients' perceptions of safety and experience of errors. Investigators found that encouragement from staff, education about patient safety, and comprehensible information all led to higher participation rates. The authors conclude that patients will be more engaged in their safety if frontline staff value patient involvement.
Sahlström M, Partanen P, Rathert C, et al. Int J Nurs Pract. 2016;22:461-469.
Providing patient-centered care calls for involving patients in all aspects of care. However, patient engagement in safety efforts remains challenging. Analyzing survey data from 21 Finnish patient safety experts, researchers determined that patient participation in maintaining their own safety varied across institutions and did not consistently meet national standards. They suggest that institutions should focus on creating a safety culture that promotes an equal partnership with patients to achieve high quality care.
Härkänen M, Kervinen M, Ahonen J, et al. Nurs Health Sci. 2015;17:188-94.
This direct observation study found that verifying patients' identity prior to medication administration, a key patient safety practice, was not routinely employed. Nurses with more experience tended to comply with the identification protocol less, underscoring the challenge of effectively implementing patient safety recommendations.
Rathert C, May DR, Williams E. Health Care Manage Rev. 2011;36:359-368.
While patients are being encouraged to take a more active role in patient safety, concerns persist that patient satisfaction may be more influenced by service quality rather than safety issues. However, this survey of hospitalized patients found that both perceptions of safety and service quality influenced overall patient satisfaction.
Rathert C, Phillips W. Journal of Business Ethics. 2010;97.
Many factors inhibit clinicians from disclosing medical errors to patients, ranging from inadequate training in error disclosure, fear of precipitating a malpractice lawsuit, and sometimes explicit discouragement of disclosure. This article draws a sharp contrast between the traditional "deny and defend" approach to error disclosure, and the "disclose and apologize" model that has been successfully implemented at some institutions. Based on survey data, the authors argue that formal error disclosure training programs for staff not only teach important skills, but promote a values-based work environment. Health care leaders, in their view, should adopt "disclose and apologize" policies, and train employees to disclose and discuss errors as a key part of improving organizational safety culture.
Rathert C, May DR. Health Care Manage Rev. 2007;32:2-11.
The authors sought to measure the relationship between nurse perception of patient-centeredness in their unit and its effect on safety. They found that nurses in an patient-centered environment were more satisfied with their jobs and more comfortable discussing and reporting errors.
Silén-Lipponen M, Tossavainen K, Turunen H, et al. Int J Nurs Pract. 2005;11:21-32.
Three categories were used to explore potential causes of error in the operating room—demanding teamwork practice, shared responsibility in teams, and organized teamwork. Results revealed that attention to workforce, management, and reporting issues has the potential to improve the situation.