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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 - 9 of 9 Results
King C, Dudley J, Mee A, et al. Arch Dis Child. 2023;108:583-588.
Medication errors in pediatric patients can have serious consequences. This systematic review identified three studies examining interventions to improve medication safety in pediatric inpatient settings. Although the three interventions – a mnemonic device, a checklist, and a specific prescribing round involving a clinical pharmacist and a doctor – reduced prescribing errors, the studies did not assess weight-based errors or demonstrate reductions in clinical harm.
Balestracci B, La Regina M, Di Sessa D, et al. Intern Emerg Med. 2023;18:275-296.
The COVID-19 pandemic extended face-masking requirements from healthcare providers to the general public and patients. This review summarizes the challenges mask wearing poses to the general public. Challenges include discomfort, communication issues, especially for people with hearing loss, and skin irritation. Despite these issues, the authors state the benefits outweigh the risks of masks and appropriate education may improve mask use.
Cheung R, Roland D, Lachman P. Arch Dis Child. 2019;104:1130-1133.
Children are vulnerable to delayed or missed diagnosis, infections, and medication errors. This commentary summarizes the current state of pediatric patient safety improvement efforts in the United Kingdom and emphasizes the importance of systems approaches to safety. The authors highlight huddles and pediatric early warning systems as two tactics that improve the reliability of communication to address the complex needs of pediatric patients.
Lachman P, Nicklin W. Healthc Manage Forum. 2017;30:233-236.
Hospital boards and executives can help drive safety improvement. This commentary suggests that organizational leadership should engage staff and peers in creating the culture change needed to launch and sustain advances in patient safety.
Lachman P, Linkson L, Evans T, et al. BMJ Qual Saf. 2015;24:337-44.
Through an iterative process, researchers developed and tested a simple tool for patients and family members to report potential harms during hospitalization. The tool led to some improvements in staff reporting and other safety behaviors, but there was no measurable change in safety culture scores for the ward during the study period. This tool is an example of the increasingly utilized strategy of engaging patients in preventing errors.
Woodhead T, Lachman P, Mountford J, et al. BMJ Qual Saf. 2014;23:619-23.
The Francis report is a seminal publication that calls for improvement of health care delivery in the National Health Service. This commentary describes initiatives that promote enhancing workforce involvement in developing understanding and skills backed by leadership and policy to achieve sustainable improvements.
Chapman SM, Fitzsimons J, Davey N, et al. BMJ Open. 2014;4:e005066.
Using a novel trigger tool to identify adverse events for hospitalized children, this retrospective chart review found that 14% of patients experienced at least one adverse event. A recent AHRQ WebM&M commentary discusses the emergence of trigger tools as a patient safety measure.