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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 24 Results
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.
I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.
Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.
Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.

Cheney C. HealthLeaders. September 4, 2020.

A blameless approach to error and near miss reporting is foundational to the success of the effort. This article discusses one organization’s persistent challenge with shifting reporting to align with a safety culture. The author describes the importance of staff education and leadership to support the focus of reporting initiatives on the system rather than individuals when failures occur.   
Prachand VN, Milner R, Angelos P, et al. J Am Coll Surg. 2020;231:281-288.
Physicians may be faced with difficult decisions regarding potential limits to patient access to care during the COVID-19 pandemic in order to preserve resources to meet the medical needs of patients diagnosed with COVID-19. This article describes a scoring system incorporating resource limitations and COVID-19 transmission risk to facilitate decision-making and triage for medically-necessary, time-sensitive procedures while balancing patient risk and public health concerns.
Cheney C. HealthLeaders Media. April 17, 2019.
… This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated … purposeful redundancy, and leadership engagement . … Cheney C. HealthLeaders Media. April 17, 2019. … C. … Cheney
Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017;127:326-337.
Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.
Murji A, Luketic L, Sobel ML, et al. Surg Endosc. 2016;30:4499-504.
Interruptions and distractions are well-recognized sources of error. Distractions in the operating room are common. In this randomized crossover study, researchers observed residents performing a virtual salpingectomy and subjected them to time periods in which they received pages versus quiet phases without interruptions. The majority of residents made at least one unsafe clinical decision while trying to multitask, further supporting that interruptions and distractions adversely impact patient safety.
Amin MM, Graber ML, Ahmad K, et al. Acad Med. 2012;87:1428-33.
First-year residents who were allowed to nap for 20 minutes at midday had improved cognitive performance and fewer attentional failures than residents who did not nap. However, the study did not control for potential confounders, such as residents' caffeine intake.

Staender S, ed. Best Pract Res Clin Anaesthesiol. 2011;25(2):109-304.  

… 2011;25(2):109-304.   … Van Aken H; van Gessel E … A. … T. … DK … G. … AF … SE … J. … KL … MS … KB … M. … P. … A. … K. … A. … R. … R. … RJ … S. … RP … AF … DH … JS … KM … G. … T. … F. … …
Fairbanks RJ, Caplan SH, Bishop PA, et al. Ann Emerg Med. 2007;50:424-432.
… used simulated resuscitation scenarios and found that a confusing user interface limited paramedics' ability to properly use two common defibrillator models. A related editorial discusses the challenge of uniting … patient safety principles and usability. … Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Usability study of …
Griffen FD, Stephens LS, Alexander JB, et al. J Am Coll Surg. 2007;204.
This retrospective analysis of 460 malpractice claims describes the types of events that contributed to unsafe care. The surgeon-reviewers identify several problems in the categories of diagnosis and treatment that occurred more frequently in the preoperative and postoperative periods than intraoperatively. The reviewers also rate the surgical care quality and whether the complications leading to the suit were preventable. The American College of Surgeons intends to use these findings to promote educational efforts and patient safety awareness around the identified areas for improvement. Anesthesia and obstetrics and gynecology have also used closed claim reviews to identify opportunities for error prevention.