The PSNet Collection

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.

SEIPS 101 and seven simple SEIPS tools.

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Holden RJ, Carayon P. BMJ Qual Saf. 2021;30:901-910.

… tools for use by practitioners, researchers, and others. … Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. …

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

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Holden RJ, Campbell NL, Abebe E, et al. Res Social Adm Pharm. 2020;16:54-61.

This usability study examined whether older adults could use a mobile application to consider the risks and benefits of anticholinergics, a high-risk medication class. The 23 participants reported an overall high usability for the application, suggesting that mobile health information technology has potential to engage patients in safety.

Interruptions in the wild: development of a sociotechnical systems model of interruptions in the emergency department through a systematic review.

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Werner N, Holden RJ. Appl Ergon. 2015;51:244-54.

Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients.

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Holden RJ, Carayon P, Gurses AP, et al. Ergonomics. 2013;56:1669-1686.

… concepts: configuration, engagement, and adaptation. … Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human …

Human factors systems approach to healthcare quality and patient safety.

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Carayon P, Wetterneck TB, Rivera-Rodriguez J, et al. Appl Ergon. 2014;45:14-25.

This commentary describes a model that combines work system and process redesign to promote human factors engineering as a patient safety improvement strategy.

Self-reported violations during medication administration in two paediatric hospitals.

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Alper SJ, Holden RJ, Scanlon MC, et al. BMJ Qual Saf. 2012;21:408-15.

Pediatric nurses reported frequently violating medication administration policies, especially in emergency situations. The impact of these protocol violations on patient safety was unclear.

What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records.

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Holden RJ. J Patient Saf. 2011;7:193-203.

… Journal of patient safety … J Patient Saf … This qualitative study identifies user, …

Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.

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Holden RJ, Patel NR, Scanlon M, et al. Research in Social and Administrative Pharmacy. 2010;6.

This study measured the type and intensity of mental demands to illustrate the complex relationships between workload and medication safety among pharmacists.

Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior.

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Holden RJ. Int J Med Inform. 2010;79:71-80.

… International journal of medical informatics … Int J Med Inform … This qualitative study revealed several themes …

A review of medical error reporting system design considerations and a proposed cross-level systems research framework.

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Holden RJ, Karsh B-T. Hum Factors. 2007;49:257-76.

The authors review the literature on medical error reporting systems and propose a model for understanding this research and applying it to system design.

Toward a theoretical approach to medical error reporting system research and design.

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Karsh B-T, Escoto KH, Beasley JW, et al. Appl Ergon. 2006;37:283-95.

The authors integrate multiple theories to construct a reporting system model that manages barriers to and facilitates implementation.

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.

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Holden RJ. Cogn Technol Work. 2011;13:11-29.

This study describes the impact of electronic health records on cognitive performance, illustrating both desirable and undesirable implications for patient safety.

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