Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 14 of 14 Results
Nemeth CP, Brown J, Crandall B, et al. Mil Med. 2014;179:4-10.
This study provides a detailed description of the overlapping technological, organizational, and human factors associated with the use of smart pumps and includes insights into potential pitfalls that may pose patient safety threats. The authors make specific recommendations to improve the real-world use of smart pump technology.
Fairbanks RJ, Wears RL, Woods DD, et al. Jt Comm J Qual Patient Saf. 2014;40:376-383.
Resilience is a characteristic that enables individuals to adapt to uncertain conditions in their work environment to prevent failure. Summarizing a workshop on how resilience can enhance patient safety, this commentary defines key elements of resilient organizations and provides examples of resilience engineering techniques applied in health care.
Perspective on Safety June 1, 2011
… are the most valid current measure of device failure. I reviewed 1,573 medical device recalls for the U.S. Food and … author is grateful to Robert Wears, MD; Shawna Perry, MD; Richard Cook, MD; and Jay Crowley for their insightful comments …
This piece discusses how adopting new technology can have unintended effects.
His seminal work in patient safety is generally credited with introducing the concept of unintended consequences.
Nemeth CP, Cook RI, Wears RL. Ann Emerg Med. 2007;50:384-6.
The authors introduce a set of articles that explore how clinicians plan and manage their work in the emergency department through the spectrum of clinical workload, learning techniques, equipment use, and communication.
Albolino S, Cook RI, O’Connor M. Cog Tech Work. 2006;9:131-137.
This study examined sensemaking within the context of the intensive care unit (ICU). The investigators used direct observation of ICU teams on rounds, in order to analyze how clinicians responded to the inherent complexity of ICU care, and to determine how clinicians attempted to avoid error and adverse outcomes. Clinicians used a variety of mechanisms to establish "cooperative conditioning," a shared understanding of the patient's acute needs and risks, which maximizes patient safety by establishing a common group culture and approach to decision making. The authors' approach is derived from the seminal study of sensemaking in organizations, an account of the Mann Gulch disaster.
Bates DW, Clark NG, Cook RI, et al. Endocr Pract. 2005;11:197-202.
The authors report on the results of a consensus conference that focused on safety for patients with diabetes and other endocrine diseases. They list the recommendations from the multidisciplinary expert panel convened for the conference.
Patterson ES, Cook RI, Render ML. J Am Med Inform Assoc. 2002;9:540-53.
This cross-sectional observational study discovered a number of unintended consequences of bar code medication administration (BCMA) technology implementation and the potential for new paths to adverse drug events. Using ethnographic observation techniques on nearly 70 nurse-BCMA interactions, investigators identified and discuss five negative side effects of the new medication process. Both conceptual and operational frameworks are presented, but the authors point out that their findings do not call for abandoning the technology. They argue that, with implementation of any new technology, redesign and anticipation of unintended effects must be considered. The technique of observation described in this study may serve as a very useful tool for similar technology advances and implementation.
Cook RI, Woods DD. Hum Factors. 2006;38:593-613.
New technology continues to offer great advances and challenges. This article takes a detailed look at technology’s impact on human performance by studying the implementation of a new physiological monitoring system for use in cardiac anesthesia. Discussion includes characteristics of the upgraded system, a process-tracing technique to examine the complex physician-computer interaction, and the problems that developed while in use. The authors introduce a number of new cognitive burdens that resulted and discuss how providers attempted to overcome these burdens within the framework of the new system. Though it represents one example, the rich discussion in this article applies to most new technology and the human factors that require it to function as technically designed.
WebM&M Case March 1, 2005
Transferred from one hospital to another for urgent evaluation, a patient is initially misdiagnosed when the CD (containing her radiographs) sent with her displays the older, rather than current, CT scans first.