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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
Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6:133.
Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.
Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.
De Brún A, Anjara S, Cunningham U, et al. Int J Environ Res Public Health. 2020;17:8673.
Leadership has an important role in promoting a culture of safety and enabling necessary changes to enhance patient safety. This article summarizes the design, pilot testing, and refinement of the Collective Leadership for Safety Culture (Co-Lead) program, which offers a systematic approach to developing collective leadership behaviors to promote effective teamwork and enhance safety culture.
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:810.
Organizational cultures that encourage psychological safety have been shown to increase safe healthcare. The authors used survey, observational, and interview data to explore psychological safety within four healthcare teams in one hospital. While survey results indicated a high level of psychological safety, observations and interviews identified examples of situations resulting in lower levels of psychological safety, such as absence of learning behavior, low levels of support from other team members, and lack of familiarity among team members.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.  
O’Donovan R, McAuliffe E. Int J Qual Health Care. 2020;32:240-250.
This systematic review analyzed 36 articles exploring factors enabling psychological safety in healthcare teams. The review identified five themes of enabling factors: (1) priority for patient safety, such as safety culture or leadership behavior; (2) improvement or learning orientation leading to a culture of continuous improvement or change-oriented leadership; (3) support from peers, leadership or the organization; (4) familiarity between and across teams and with team leaders, and; (5) status, hierarchy and inclusivity. These themes can aid future objective measures of psychological safety and interventions to improve psychological safety within teams. 
Ward M, Shé ÉN, De Brún A, et al. BMC Med Edu. 2019;19:232.
“Serious games” are becoming more prevalent in health care. This article describes a "serious game" PlayDecide for use of multidisciplinary healthcare teams in which the teams are presented with real-world case stories of events and incidents, incorporating the perspectives of healthcare professionals and patients. Players are tasked with exchanging and discussing perspectives and information, then working towards a shared group policy position around error reporting and patient safety. This study evaluated the use of the PlayDecide framework in two large urban academic medical centers and noted a significant change in error reporting behavior among junior faculty post-intervention. 
Ward ME, De Brún A, Beirne D, et al. Int J Environ Res Public Health. 2018;15:E1182.
Change initiatives require broad-based collective design strategies to ensure the range of needs are addressed. This commentary explains how one hospital group used codesign methods to engage leadership in a teamwork and culture improvement project. The authors describe specific tools and tactics used to implement the work and summarize the value of the approach for other health care organizations.
Sicherer SH, Allen K, Lack G, et al. Pediatrics. 2017;140.
Diagnostic error can result in physical, psychological, and financial patient harm. This commentary discusses key findings of a consensus report and highlights challenges associated with diagnosing and treating food allergies. The authors recommend process changes and research directions to help improve allergy identification and management specific to pediatric care.

J Oncol Pract. 2016;12(11):955-1194.

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Patton BS, Donovan KJ. Air Med J. 2015;34:264-8.
This commentary describes how an air transport unit at one hospital developed a safety culture while working toward obtaining accreditation. Key areas of improvement focused on addressing crew fatigue and improving team communication.
Kanaan AO, Donovan JL, Duchin NP, et al. J Am Geriatr Soc. 2013;61:1894-1899.
Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.
Field T, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-7.
Warfarin therapy is commonly associated with adverse events despite specific indicators designed to capture them and guide prevention efforts. This study adopted the SBAR communication tool as part of a protocol to improve the quality of warfarin management in the nursing home setting. Using a facilitated telephone communication between nurses and physicians in 26 nursing homes, the patients randomized to the SBAR approach had statistically significant improvements in their therapeutic levels and a non-statistically significant reduction in adverse events. A past AHRQ WebM&M commentary discusses a case of inadequate warfarin monitoring that resulted in an adverse event for a nursing home patient.