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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 35 Results
Ravindran S, Matharoo M, Rutter MD, et al. Endoscopy. 2023;Epub Sept 18.
Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.
Congenie K, Bartjen L, Gutierrez D, et al. Jt Comm J Qual Patient Saf. 2023;49:716-723.
Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organization-wide standardized dashboards and summaries, thus allowing for local and systemwide improvements.
Garrod M, Fox A, Rutter P. JAMIA Open. 2023;6:ooad057.
Understanding causes of wrong-patient order entry (WPOE) can help develop interventions to reduce those medication errors. This review summarizes how organizations and providers identify WPOE, what data are being captured, and causes. The most common organizational detection method is the retract-and-reorder method whereby a medication order is cancelled then reordered on a different patient within a specified period of time. There was minimal data on how providers detect their own WPOE errors. Technology and physician workload were identified as contributors to WPOE.
D’Angelo A-LD, Kapur N, Kelley SR, et al. Surgery. 2023;174:222-228.
Prior research has asked surgeons how they cope with intraoperative errors, but this study asks operating room personnel how they perceive surgeons' coping strategies. Positive response strategies included announcing that an error has occurred and the plan for managing it. Negative responses include the surgeon becoming visibly upset, raising their voice, and blaming others. The authors suggest additional education on positive strategies to cope with errors during medical education and residency.
Skeff KM, Brown-Johnson CG, Asch SM, et al. J Healthc Manag. 2022;67:339-352.
Electronic health records (EHRs) can improve patient safety but can also contribute to physician burnout. This qualitative study involving physicians and medical trainees found that distress most often occurred when physicians were prioritizing systems-based practice (e.g., EHR-required documentation) over other professional activities, such as patient care, communication, and practice-based learning.  
D'Angelo JD, Lund S, Busch RA, et al. Surgery. 2021;170:440-445.
This study evaluated the type and effectiveness of resident and faculty coping strategies following an intraoperative error and the interaction with physician gender. Results show that while men and women surgeons experience adverse events at approximately the same rate, the coping methods utilized and effectiveness of the methods varied.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
J Patient Saf Risk Manag … The July effect is a phenomenon … Vincent C, Shapiro DW, et al. Mitigating the July effect. J Patient Saf Risk Manag. 2021;26(3):93-96. …
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156:76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.
Salmasian H, Blanchfield BB, Joyce K, et al. JAMA Netw Open. 2020;3:e2019652.
Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.  
Copi EJ, Kelley LR, Fisher KK. J Am Pharm Assoc (2003). 2018;58:S46-S50.
Community pharmacy dispensing errors are an important cause of ambulatory adverse drug events. In this academic health system, 5% of prescriptions were dispensed inadvertently—the providers had ordered to discontinue them. Most unintentionally dispensed prescriptions were high-risk medications, such as anticoagulants, insulin, and diuretics.
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
… the global impact of the World Health Organization's efforts to improve patient safety. … Geneva, Switzerland: … Veillard,Jeremy Henri Maurice; Leatherman,Sheila; Syed,Shamsuzzoha; Kim,Sun Mean; Nejad,Sepideh Bagheri; … (English). Washington, D.C. : World Bank Group … T. … Kelley,Edward … T. Kelley,Edward …
Painter LM, Kidwell KM, Kidwell RP, et al. J Patient Saf. 2018;14:87-94.
Disclosing medical errors to patients and families is considered essential for maintaining a therapeutic relationship and a core tenet of medical professionalism, but less is known about the impact of disclosure on malpractice claims and compensation. In this study, researchers sought to understand the effect of state legislation requiring disclosure of serious events to patients. Using data from a single, large health care system, they found that although the number of serious event disclosures increased between May 2002—the year the legislation was enacted—and June 2011, the rate of malpractice claims remained stable. Claims that were disclosed and claims that involved greater harm were associated with increased compensation. An accompanying editorial highlights some of the advantages of comprehensive disclosure programs.
Gooden R, Syed SB, Rutter P, et al. Community Dev J. 2013;49.
This commentary provides information about an approach to augment patient safety through public health engagement. Implemented in partnership with six African countries to spread and sustain safe care practices, the initiative utilized a seven-component model to bring together community leaders and hospitals to drive improvement. A recent AHRQ WebM&M perspective covered lessons learned throughout implementation of the program.
Rutter P, Brown D, Howard J, et al. Drug Saf. 2014;37:465-9.
Pharmacists continue to play a critical role in reducing medication errors. Exploring ways to enhance the role of community pharmacists in medication safety, this commentary advocates for providing education about the importance of reporting adverse drug events and training to improve diagnostic skills.
J Public Health Res. 2013;2:e22-e33.
… skills, incident reporting , and error disclosure . … J Public Health Res. 2013;2:e22-e33. … AW … DJ … G. … KM … O. … S. … PR … JT … I. … MC … H. … JC … T. … PJ … JR … J. … BH … JV … AF … E. … T. … Wu … Boyle … Wallace … Mazor … Guillod … Petronio … …
Rutter CM, Johnson E, Miglioretti DL, et al. Cancer Causes & Control. 2011;23.
This study of more than 45,000 colonoscopies found that 4.7 serious adverse events occurred per 1000 screening colonoscopies. Advanced age and the need for polyp removal were associated with increased risk of adverse events.