Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 28 Results
Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.
Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.
Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2021;17:e335-e342.
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.
Manojlovich M, Frankel RM, Harrod M, et al. BMJ Qual Saf. 2019;28:160-166.
Researchers describe the use of video reflexive ethnography to improve communication between physicians and nurses during rounds at a single academic medical center. They conclude that video reflexive ethnography is feasible and may have the potential to improve communication between physicians and nurses.
Ziring D, Frankel RM, Danoff D, et al. Acad Med. 2018;93:1700-1706.
Unprofessional and disruptive behavior among health care personnel can adversely impact safety, but reporting and addressing such behavior remains challenging. In this mixed-methods study, researchers identify barriers faculty may face when reporting student lapses in professionalism.
Hannawa AF, Frankel RM. J Patient Saf. 2021;17:e1130-e1137.
Effective error disclosure fosters a just culture. In this large study, participants responded to actors as they disclosed a minor error and a sentinel event. When physicians communicated their remorse nonverbally, participants had less desire to distance themselves from the physician or seek legal action.
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
McDonald KM, Su G, Lisker S, et al. Implement Sci. 2017;12:79.
Diagnostic error in the ambulatory care setting is common, particularly with regard to missed or delayed diagnoses of cancer. This study used human factors engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor patients with high-risk conditions and to identify vulnerabilities in the monitoring process that could lead to delayed diagnoses.
Patterson ES, Sillars DM, Staggers N, et al. Jt Comm J Qual Patient Saf. 2017;43:375-385.
Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.
Rattray NA, Sico JJ, Cox LAM, et al. Jt Comm J Qual Patient Saf. 2017;43:127-137.
Communication between inpatient clinicians and primary care physicians at the time of hospital discharge is often suboptimal, and it may not have improved with the advent of electronic health records. This qualitative study examined barriers to inpatient–outpatient communication in the care of stroke patients and found that clear communication is needed to ensure effective handoffs.
O'Brien CM, Flanagan ME, Bergman AA, et al. BMJ Qual Saf. 2016;25:76-83.
This qualitative analysis of verbal handoffs within physician dyads and within nurse dyads found that most questions during handoffs came from incoming providers, who were typically requesting additional information or seeking consensus on clinical reasoning. These results complement a recent study that also supported adding interactive questioning to structured handoff communication.
Bergman AA, Flanagan ME, Ebright PR, et al. BMJ Qual Saf. 2016;25:84-91.
This qualitative analysis found that anticipatory management conversation occurred in most physician-to-physician and nurse-to-nurse verbal handoffs. The authors suggest that structured handoffs should be supplemented with additional verbal communication regarding relevant contextual information.
Hilligoss B, Mansfield JA, Patterson ES, et al. Jt Comm J Qual Patient Saf. 2015;41:134-143.
Handoffs transfer accountability for a patient from one clinician to another. This commentary proposes a framework for transfers from the emergency department to other units within the hospital that highlights environmental, organizational, and social factors that affect these interactions to augment handover quality.
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. BMJ Qual Saf. 2014;23:483-9.
Researchers performed direct observation of nurse and physician handoff communication to assess their use of interactive questioning, a recommended aspect of this approach. Experienced providers utilized more interactive questioning, and physicians used interactive questioning more often than nurses. These results suggest that providers acquire handoff skills over time and that such techniques may be needed in education for less experienced providers.
Russ AL, Zillich AJ, McManus S, et al. Int J Med Inform. 2012;81:232-43.
This study provides a framework to understand the increasing importance of the prescriber–alert interaction in computerized provider order entry systems. The alert interface is a key element in influencing providers and promoting patient safety.