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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 39 Results
Martin G, Stanford S, Dixon-Woods M. BMJ. 2023;380:513.
The Francis report served as a call to action for improvement, following its recording of elements contributing to systemic failure within the British National Health Service (NHS). This commentary considers the overarching problems that still exist at the NHS and that listening, learning, and leadership involvement are core elements for driving and realizing lasting change throughout the system.
Engel FD, da Fonseca GGP, Cechinel-Peiter C, et al. J Patient Saf. 2023;19:e46-e52.
Due to the infectious and deadly nature of COVID-19, heath care facilities were forced to change many of their person-centered policies, including restriction on visits from family and friends. This review highlights factors that impacted hospitalized patients during COVID-19. Thirty-two studies were identified and classified into three main factors: concern about the patient’s well-being during hospitalization, communication and interaction between patients, families, and care team, and the impact on the health care organization.
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgery. 2022;172:537-545.
The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) and outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.
Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.
Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
The July effect is a phenomenon that presumably results in poor care due to the annual en masse introduction of new doctors into practice. This commentary outlines factors undermining the safe influx of these new clinicians into active, independent practice. The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible.
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. BMJ Qual Saf. 2020;29:550-559.
There is uncertainty about the effectiveness of cognitive debiasing in reducing bias that can contribute to diagnostic error. Instead of focusing on the process of reasoning, this study examined whether an intervention directed at refining knowledge of a cluster of related disease can ‘immunize’ physicians against bias. Ninety-one internal medicine residents in Brazil were randomized to one of two sets of vignettes (reflecting diseases associated with either chronic diarrhea or jaundice) and compared/contrasted alternative diagnoses. After residents encountered one case of a disease, non-immunized residents twice as likely to give that incorrect diagnosis to a different (but similar) disease, resulting in a 40% decrease in diagnostic accuracy between immunized and non-immunized physicians.
Long E, Barrett MJ, Peters C, et al. Paediatr Anaesth. 2020;30:319-330.
Intubation occurring outside the operating room (OR) is rare but associated with life-threatening adverse events. This review provides an overview of situational, physiological and anatomical contributors to intubation of children outside of ORs; situational challenges – such as human factors or unfamiliar equipment – are most common. Potential solutions to reduce intubation-related adverse events and improve patient safety are discussed, such as systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, multi‐disciplinary team engagement and training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance.
Sedlock EW, Ottosen M, Nether K, et al. J Patient Saf Risk Manag. 2018;23:167–175.
… … EW … M. … K. … DF … JM … A. … N. … L. … L. … R. … A. … C. … A. … EJ … Sedlock … Ottosen … Nether … Sittig … Etchegaray … Tomoaia-Cotisel … Francis … Yager … Schafer … Wilkinson … Khan … Arnold … … A. Tomoaia-Cotisel … N. Francis … L. Yager … L. Schafer … R. Wilkinson … A. Khan … C. Arnold … A. Davidson … EJ Thomas …
Dhillon NK, Francis SE, Tatum JM, et al. JAMA Surg. 2018;153:1052-1053.
In this prospective study, researchers found that decreasing the number of computers on wheels during rounds in a single surgical intensive care unit was associated with a significant reduction in simultaneous conversations and improved ability to hear patient presentations. The authors conclude that participants may be more engaged during rounds when information is obtained from presentations rather than having the electronic medical record readily available on a computer.
Abbott JF, Pradhan A, Buery-Joyner S, et al. J Patient Saf. 2016;16:e39-e45.
Incorporating patient safety education for medical students in various practice environments can enhance health care safety. This commentary describes efforts to integrate patient safety concepts into medical education and highlights the importance of including such curricula in obstetrics and gynecology. A past PSNet Annual Perspective discussed safety and medical education.
Moffatt-Bruce SD, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;102:358-62.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.

Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.

… Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000. … MP … BD … Tully … …
Sanchez JA, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;101:426-33.
The Society of Thoracic Surgeons National Database collects data to promote transparency and enhance technical expertise. Exploring safety sciences in cardiothoracic surgery, this commentary discusses how human error, accident causation, and high reliability can improve safety of care delivered by cardiac surgical teams.
Hollnagel E, Braithwaite J, Wears RL, eds. Aldershot, UK: Ashgate Publishing; 2013-2016; Boca Raton: Taylor & Francis; 2018; New York, NY: Routledge; 2019.
… UK: Ashgate Publishing; 2013-2016; Boca Raton: Taylor & Francis; 2018; New York, NY: Routledge; 2019. … RL … E. … J. …
Ahmed A, Ahmad M, Stewart M, et al. Laryngoscope. 2015;125:837-41.
This direct observation study revealed that surgeons performed with less dexterity and made more errors when distractions were present in the operating room compared to when no distraction occurred, and this effect was more pronounced in those with less experience. Consistent with prior work on interruptions and distractions, this finding underscores the need to augment health care work environments to improve safety.