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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 - 5 of 5 Results
Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11:e256-e262.
Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.  
Jung OS, Kundu P, Edmondson AC, et al. Jt Comm J Qual Patient Saf. 2021;47:15-22.
Psychological safety can empower health care workers to communicate concerns and improve care. This survey of radiation oncology staff found that near misses are not processed and reported equally. The odds of reporting near misses and events resulting in harm improved with increased psychological safety. The authors conclude that educating health care workers to identify near misses and fostering psychological safety can increase reporting and improve patient safety.
Herrigel DJ, Carroll M, Fanning C, et al. J Hosp Med. 2016;11:413-7.
Interhospital transfers have similar risks as other care transitions, but less is known about them. This descriptive study found variation in the training and experience of transfer care coordinators and communication practices in handoffs. Standardization in these practices should enhance patient safety.
Edmondson AC, Higgins M, Singer SJ, et al. Res Hum Dev. 2016;13:65-83.
Ensuring that workers feel comfortable raising concerns in an organization is crucial to facilitating learning from failures. Exploring how psychological safety influences staff communication about problems in education and health care, this commentary describes similar challenges in both settings associated with hierarchy, leadership, and professional roles. The authors outline areas of research needed to understand ways to improve transparency in each environment.