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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 - 8 of 8 Results
Fridman M, Korst LM, Reynen DJ, et al. Jt Comm J Qual Patient Saf. 2023;49:129-137.
Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.
WebM&M Case February 1, 2017
A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.
Donaldson N, Aydin C, Fridman M, et al. J Healthc Qual. 2014;36:58-68.
This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.
Donaldson N, Aydin C, Fridman M. J Nurs Adm. 2014;44:353-61.
This direct observation study of nursing medication administration demonstrated that adherence to safe practices such as minimizing interruptions, checking two forms of patient identification, discussing medications with patients and their families, and prompt documentation led to fewer medication administration errors. Characteristics such as higher patient-to-nurse ratios and patient turnover were associated with decreased adherence to safe practices, emphasizing the crucial role of nursing workload in patient safety.
Donaldson N, Shapiro S, Scott M, et al. J Nurs Adm. 2009;39:176-81.
Rapid response teams (RRTs) have proven to be very popular among bedside nursing staff, contributing to their widespread implementation despite equivocal evidence of clinical benefits. This study carried out interviews with nurses, chief nursing officers, and RRT members at 18 hospitals to obtain insights on how to successfully implement RRTs. Themes that predicted successful implementation included clear organizational support for the RRT, support for bedside nurses when the team is called, and less resistance from physicians to using the RRT.
Denham CR, Dingman J, Foley M, et al. J Patient Saf. 2008;4:148-161.
This article discusses verbal communication and how human factors, authority gradients, team interaction, health literacy, and active listening can affect safety improvement.
WebM&M Case November 1, 2005
… an institution’s ability to promote a culture of safety. … Mary E. Foley, MS, RN … Associate Director, Center for Research & … 11. Kohn LT, Corrigan JM, Donaldson MS, eds, Committee on Quality of Health Care in …