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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 21 Results
Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.
Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.
Perspective on Safety June 1, 2019
… State University of New York at Buffalo Buffalo, NY … Rollin J. Fairbanks, MD, MS … Vice President of Quality and Safety, …
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.
Perspective on Safety August 1, 2015
… Georgetown University School of Medicine Washington, DC … Rollin J. (Terry) Fairbanks, MD, MS … Director National Center for Human …
This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Hettinger Z, Fairbanks RJ, Hegde S, et al. J Healthc Risk Manag. 2013;33:11-20.
… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … The authors reviewed 334 root cause … analyses (RCA) using systems science principles to create a toolkit for applying RCA results to make practice changes. …
Fairbanks RJ, Crittenden CN, O’Gara KG, et al. Acad Emerg Med. 2008;15:633-640.
This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.
Wang HE, Fairbanks RJ, Shah M, et al. Ann Emerg Med. 2008;52:256-62.
This study of closed malpractice claims against prehospital emergency medical services found that clinical management was an infrequent source of malpractice allegations, trailing emergency vehicle accidents and patient handling mishaps.
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.