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 - 11 of 11 Results

How do simulated error experiences impact attitudes related to error prevention?

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Breitkreuz KR, Dougal RL, Wright MC. Simul Healthc. 2016;11:323-333.

… … Simul Healthc … Growing evidence supports the use of simulation training as a powerful tool in medical education. Investigators provided … the other watched movies about error; both groups reviewed a standard curriculum on medication errors . The authors …

Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.

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Segall N, Bonifacio AS, Barbeito A, et al. Jt Comm J Qual Patient Saf. 2016;42:400-14.

… Joint Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Human factors … identified flaws in handoff practices; then they designed a standardized handoff process to address these …

In situ simulated cardiac arrest exercises to detect system vulnerabilities.

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Barbeito A, Bonifacio AS, Holtschneider M, et al. Simul Healthc. 2015;10:154-62.

Realistic in situ simulations of cardiac arrest scenarios, conducted in actual clinical settings without advance notification of participants, identified several latent errors in a hospital's emergency response system. Dr. David Gaba, a pioneer in simulation in health care, was interviewed for AHRQ WebM&M in 2013.

FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

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Barbeito A, Lau WT, Weitzel N, et al. Anesth Analg. 2014;119:777-83.

… Analg … This commentary describes lessons learned from a multidisciplinary initiative developed to enhance safety of cardiac surgery . The intervention focused on identifying …

Handovers from the OR to the ICU.

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Bonifacio AS, Segall N, Barbeito A, et al. Int Anesthesiol Clin. 2013;51:43-61.

… Clin … This commentary discusses concerns associated with patient transfers from the operating room to the intensive …

Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project.

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Turner K, Frush K, Hueckel RM, et al. J Nurs Care Qual. 2013;28:257-64.

… Journal of nursing care quality … J Nurs Care Qual … The Josie King Care Journal is a tool intended to improve communication between the health … This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was …

Can we make postoperative patient handovers safer? A systematic review of the literature.

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Segall N, Bonifacio AS, Schroeder RA, et al. Anesth Analg. 2012;115:102-15.

… clinical tasks prior to information transfer, allowing patient-specific discussion during verbal handovers, and … training in team and communication skills would improve patient handovers . …

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

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Fuchs MA, Sexton DJ, Thornlow D, et al. J Nurs Care Qual. 2011;26:101-9.

… Journal of nursing care quality … J Nurs Care Qual … Adoption of a nurse-driven checklist led to reductions in catheter days and catheter-associated urinary tract infections . A past AHRQ WebM&M perspective discussed solutions to …

A necessary sea change for nurse faculty development: spotlight on quality and safety.

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Thornlow D, McGuinn K. J Prof Nurs. 2010;26:71-81.

… Journal of professional nursing : official journal of the American Association of Colleges of Nursing … J Prof Nurs … This article explains the need to incorporate safety and quality concepts into undergraduate nursing …

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.

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Thornlow D, Anderson RA, Oddone E. Int J Nurs Stud. 2009;46:1528-1535.

This paper discusses the role of nursing care in preventing missteps that may trigger larger adverse events in hospitalized elderly patients.

Time of Death?

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WebM&M Case September 1, 2005

… was found pulseless and cyanotic in her hospital bed. A code was called, which involved intubation, the … team communication, and (v) the impact of time stress. Let’s first focus on some of the issues in ACLS education. … High … Dean for Educational Technology Duke University … Melanie C. Wright, PhD … Assistant Professor of …

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