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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 - 11 of 11 Results
Mazotti LA, Vidyarthi AR, Wachter RM, et al. J Hosp Med. 2009;4.
After the implementation of duty hours regulations, approximately one-quarter of internal medicine residents reported spending less time teaching. Interestingly, residents who taught less were also less likely to report emotional exhaustion, and were more likely to report satisfaction with the quality of care they provided.
Sehgal NL, Wachter RM. J Hosp Med. 2007;2:366-371.
This survey of nurse leaders at academic medical centers found great variation in the method used to document patients' do-not-resuscitate (DNR) status. Documentation could be found in the paper chart or electronic medical record, by means of a color-coded wristband, or combinations of these sources. Multiple wristband colors were used to indicate DNR status at different hospitals. This lack of standardization has been recognized as a patient safety problem, and resources exist to create standardized wristbands. The authors call for development of national standards for DNR documentation. In the same issue, the authors share an anecdote (see Associated Image link below) of a patient transferred from one acute facility to another with confusion that resulted from his multiple color-coded wristbands.
Wachter RM. Health Aff. 2004;23.
This commentary discusses the progress made since the IOM report by reviewing the context to the patient safety movement, how health care became so unsafe, and what broad categories have played a role in shaping the current patient safety milieu. The author, who also wrote Internal Bleeding, provides a grade for the broad categories impacting safety efforts, which include regulation, error-reporting systems, information technology, the malpractice system, and workforce and training issues. Two similar articles reflected on this 5-year period, one published in the New England Journal of Medicine and the other in the Journal of the American Medical Association.
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2011;21.
Focused efforts to enhance teamwork and communication have led to improved safety culture, though the impact on clinical outcomes is mixed. This multicenter study evaluated the impact of a series of teamwork and communication interventions over a 2-year period. The interventions included a teamwork training program, the development of unit-based safety teams, and patient engagement through daily goals and whiteboard use. Although a related study demonstrated that the interventions led to improved safety culture, this study found no impact on readmission rates or length of stay. Interviewing patients both during and after hospitalization, investigators found that patients perceived greater team function, but that they also perceived more safety gaps. This raises the possibility that patients' heightened awareness regarding patient safety and teamwork may lead them to identify more flaws in the system.