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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 - 20 of 213 Results

Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

… Handoffs occur several times during a surgical procedure, increasing the risk of communication … … Wolf … Traylor … Shuffler … Wiper … Riesenberg … Davis … Heng … Vong … O'Hagan … AJ … MM … ND … I … F … E … N … O … R … AT … N … A … K … E … L … M … A … D … Collaborative … J … …
Marsh KM, Turrentine FE, Schenk WG, et al. Ann Surg. 2022;276:e347-e352.
The perioperative period represents a vulnerable time for patients. This retrospective review of patients undergoing surgery at one hospital over a one-year period concluded that medical errors (including, but not limited to, technical errors, diagnostic errors, system errors, and errors of omission) were strongly associated with postoperative morbidity.
Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.
… venous thromboembolism (VTE) continues to be a significant source of preventable patient harm . This study … (e.g., intermittent compression). … Richie CD,  Castle JT, Davis GA, et al. Modes of failure in venous thromboembolism …
Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Patient Saf Surg. 2022;16:7.
Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.
Patient Safety Primer March 12, 2021
… safety field. … Background … Medication errors have been a key target for improving safety since Bates and colleagues' … errors and adverse drug events and on the pharmacist's role in medication safety , the medication-use process is … PharmD, BCPS … Department of Pharmacy Services UC Davis Health … Ann Cabri, PharmD … Department of Pharmacy …
Abrams EM, Shaker M, Oppenheimer J, et al. J Allergy Clin Immunol Pract. 2020;8:2474-2480.e1.
This article discusses the challenges COVID-19 poses for shared decision making (such as physical distancing and health service reallocation, communicating uncertainty, delivering allergy/immunology care) and opportunities to evolve incorporation of shared decision making into clinical practice during and after the pandemic.

Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5.

… identified using unclear or misleading abbreviations as a threat to patient safety . This article discusses proposed solutions, and provides a rationale for why some solutions may not be feasible. … Davis N. ISMP Medication Safety Alert! Acute care edition!  …
Donnelly EA, Bradford P, Davis M, et al. CJEM. 2019;21:762-765.
… conducted in ten paramedic services in Ontario, Canada—of a relationship between fatigue and paramedic-reported safety … fatigue mitigation efforts.  … Donnelly EA, Bradford P, Davis M, Hedges C, Socha D, Morassutti P. Fatigue and Safety …
Bourgeois FC, Fossa A, Gerard M, et al. J Am Med Inform Assoc. 2019;26:1566-1573.
OpenNotes enables patients and their designated caregivers to access medical records and provider documentation. Research has shown that this access may have the potential to improve medication adherence and patient engagement, and that patients may be able to identify errors in documentation. In this study performed at three distinct medical centers, researchers evaluated the effects of implementing a system for patients and families to report mistakes they saw in outpatient documentation. Of the 1440 reports obtained, 27% suggested possible inaccuracies and frequently prompted a change in the medical record. Symptom descriptions, past medical history, and medications were most commonly identified as areas of potential discrepancy by patients and families. An Annual Perspective discussed mechanisms for engaging patients as partners in safety.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.
Rangachari P, Dellsperger KC, Fallaw D, et al. Qual Manag Health Care. 2019;28:84-95.
… reconciliation . Investigators found that there was a lack of understanding about both the technical process of … and the workflow needed. The authors suggest applying a sociotechnical model to enhance medication reconciliation …