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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 28 Results
Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26:381-387.
Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.

LeCoze JC, Pettersen K, Reiman T, eds. Safety Sci. 2014;67:1-70.

… … Ron … Andrew … Andrew … Erik … James … Jean-Christophe … Robert … Teemu … Terje … Pettersen … Almklov … Rosness … … … Westrum … Hale … Hopkins … Hollnagel … Nyce … Le Coze … Wears … Reiman … Aven … G. … K. … W.A … S. … M. … L. … Kenneth Pettersen … Petter G. Almklov … Ragnar Rosness … …
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.
Patterson ES, Wears RL. Jt Comm J Qual Patient Saf. 2010;36:52-61.
Resident work-hour restrictions and The Joint Commission have provided two drivers in recent years for improving patient handoffs. Despite efforts to develop standardized approaches, providers remain concerned about the impact of inadequate handoffs. This study reviewed nearly 400 articles to outline the seven primary functions of handoffs with each tied to a set of different interventions for improvement. The functions included information processing, narratives, accountability, social interaction, and cultural norms. The authors suggest that the diversity in handoff measurement reflects the lack of consensus about the primary purpose of a handoff, and that the definition should avoid an overly narrow construct. An accompanying editorial [see link below] highlights the challenges in developing handoff improvement strategies. A past AHRQ WebM&M commentary discussed a case of a handoff error that led to an adverse event.
van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-8.
Alerts within a computerized provider order entry system were not able to prevent medication errors resulting from drug–drug interactions. The authors hypothesize that the inadequacy of the alerts themselves was responsible for this failure, with problems including an excessive number of false-positive alerts and unclear instructions for preventing drug interactions.
Cheung DS, Kelly JJ, Beach C, et al. Ann Emerg Med. 2010;55:171-80.
Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
van der Sijs H, Aarts J, van Gelder T, et al. J Am Med Inform Assoc. 2008;15:439-48.
This study examined nearly 2000 drug–drug interaction (DDI) alerts that were overridden by providers and noted differential triggers based on clinician knowledge or specialty. The authors conclude that simply turning off DDI alerts is limited by these differential triggers and inconsistent drug monitoring, which may raise safety concerns that are prevented by the alerts themselves.
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.