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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 22 Results
Lackie K, Hayward K, Ayn C, et al. J Interprof Care. 2023;37:187-202.
… and poorly designed and delivered simulations. … Lackie K, Hayward K, Ayn C, et al. Creating psychological safety in … simulation for health professional learners: a scoping review of the barriers and enablers. J Interprof …
Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133:698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.
Bion J, Aldridge CP, Girling AJ, et al. BMJ Qual Saf. 2021;30:536-546.
In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.
Manaseki-Holland S, Lilford RJ, Te AP, et al. Milbank Q. 2019;97:228-284.
Measuring patient safety remains an ongoing challenge. This systematic review examined whether preventable death rates could be used as a measure of hospital quality. Researchers reviewed 23 studies and found that estimates of preventable in-hospital death are consistently low. Ascertainment of preventability was not consistent across multiple clinician-reviewers, and the authors estimate that cases would need review by eight or more clinicians to achieve the precision required. The authors conclude that preventable death rates would not be a valid or reliable measure of patient safety. A past PSNet interview discussed the development of hospital standardized mortality ratios and their role in monitoring performance.
Manojlovich M, Hofer TP, Krein SL. J Patient Saf. 2021;17:e732-e737.
Communication problems persistently contribute to medical error. This review focuses on the exchange of information between care team members. The authors describe an eight-element framework that targets trust, hierarchy, and technology as an approach to communication improvement that embraces the interpersonal nature of safe health care delivery.

Benzon HT, Anderson TA, eds. Anesth Analg. 2017;125(5):1427-1778.

… to the opioid epidemic and how anesthesiologists have a role in developing solutions. Topics covered include … … E. … DJ … NB … SM … LR … K. … MA … S. … CL … CR … EY … P. … E. … JP … RD … JC … EM … SA … RJ … GA … D. … MS … C. … D. … C. … T. … Y. … Y. … T. … S. … I. … K. … J. … A. … A. … M. … TR … …
Jordan KP, Timmis A, Croft P, et al. BMJ. 2017;357:j1194.
Missed and delayed diagnoses are an increasingly recognized patient safety problem. A common undiagnosed symptom in outpatient medicine is chest pain. This retrospective cohort study compared outcomes for three groups of patients with chest pain: those whose pain remained undiagnosed after 6 months versus those diagnosed with either coronary artery disease or a verified noncardiac cause of chest pain. Only a minority of the undiagnosed patients underwent diagnostic testing for coronary artery disease. The highest risk of myocardial infarction was in patients with diagnosed coronary artery disease, but undiagnosed patients were more likely to have a myocardial infarction than those with verified noncardiac disease. The authors conclude that patients without a timely diagnosis merit further evaluation to reduce the risk of cardiovascular events.
Singh H, Graber ML, Hofer TP. J Patient Saf. 2019;15:311-316.
Efforts to reduce diagnostic errors are hindered by the lack of effective measures to track improvement. This commentary proposes a set of measures for consideration that have the potential to structure research and evaluation of diagnosis improvement initiatives.
Neuhaus C, Hofer S, Hofmann G, et al. Anesth Analg. 2016;122:2059-63.
Although aviation safety strategies such as checklists and team briefings are widely considered to be valuable in health care, evidence regarding their impact has been mixed. Discussing barriers to surgical team adoption of aviation safety principles, this commentary provides a framework to guide briefings about anesthesia inductions.
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. BMJ Qual Saf. 2017;26:408-416.
Ascertaining whether adverse events are preventable is a continuing challenge in patient safety. Comparing two scales that assess preventability for mortality, this study found that there is high variability among experts rating the preventability of the same mortality event. These results suggest that preventability remains subjective despite attempts to define it in a reproducible fashion.
Dandoy CE, Davies SM, Flesch L, et al. Pediatrics. 2014;134:e1686-e1694.
Improving alarm systems to mitigate the risks of alarm fatigue was added as a National Patient Safety Goal in the 2014 update. This study introduced a multifaceted cardiac monitor care process on a pediatric bone marrow transplant unit. The program included standardized steps for ordering and reassessing cardiac monitor parameters. In addition, physicians and nurses used a log to document the need for ongoing cardiac monitoring and created reliable systems for discontinuation of monitoring when it was no longer needed. Patients and families were actively engaged in these activities, helping sustain the program. As compliance with the process improved from 38% to 95%, the number of alarms per patient-day plummeted from 180 to 40. The hope is that reducing unnecessary alerts will address clinician desensitization to clinically important alarms.
Krein SL, Kowalski CP, Hofer TP, et al. J Gen Intern Med. 2012;27:773-9.
… certain health care–associated infections (HAIs), remains a subject of debate . This study assessed the effect of the … Affairs hospitals (which do not receive CMS payments) as a comparison group. Infection control practitioners at both federal and non-federal hospitals reported a greater organizational emphasis on HAI prevention and …
Hofer TP, Hayward RA. Ann Intern Med. 2002;137:327-333.
… Med. … Ann Intern Med … The authors present the case of a patient with multiple medical problems who suffers … to define. This article is part of "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors. …
Kachalia A, Shojania KG, Hofer TP, et al. Jt Comm J Qual Saf. 2003;29:503-11.
This comprehensive literature review evaluated more than 5000 citations to determine the impact full disclosure policies have on malpractice liability. The authors present a summary of the 20 states with disclosure policies, the theoretical advantages and disadvantages of implementing such policies, and then a series of examples from investigations that examined risk factors for medical malpractice suits. Notable factors suggested from the literature include poor communication with patients, the presence of negligence, socioeconomic status, patient complaints, and physician performance during training. Despite the extensive and existing body of literature available, the authors conclude that minimal evidence directly links the effect of full disclosure on malpractice liability. Another study specifically described patient and physician attitudes towards the disclosure process.