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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 - 5 of 5 Results
Panzer RJ, Gitomer RS, Greene WH, et al. JAMA. 2013;310:1971-80.
This commentary relates challenges to meaningful and accurate quality measurement and makes recommendations to augment health care systems to improve adoption and use of quality measures.
McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.
Using defined best practices can reduce rates of central line–associated bloodstream infections (CLABSIs). Many different national initiatives aim to widely spread these evidence-based practices across medical centers. This article describes the iterative process and lessons learned by a university medical center during a 7-year initiative to decrease CLABSIs. Stakeholder buy-in and culture change are specifically highlighted as important features. The authors note that changing the culture and practice of medical and nursing staff can be difficult, taking time and perseverance. An AHRQ WebM&M perspective by Dr. Timothy Hoff discusses how to establish a safety culture.
Sax HC, Browne P, Mayewski RJ, et al. Arch Surg. 2009;144:1133-1137.
… Arch Surg … Arch Surg … As a means of improving safety, many institutions are … room (OR) personnel at two hospitals participated in a one-day, aviation-based training exercise, which emphasized … editorial [see link below] discusses the study’s findings and other drivers that may provide solutions to …
Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23 Suppl 1:41-5.
Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.