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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 29 Results
Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6:133.
Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.
Boskeljon‐Horst L, Sillem S, Dekker SWA. J Contingencies Crisis Manag. 2022;31:372-391.
High-reliability organizations frequently assess the strength of their safety culture. In this article, researchers compare the results of a safety culture assessment (SCA) of a helicopter squadron and investigation of an accident that occurred shortly after survey administration. Results of the SCA showed the safety culture was mature, but the investigation revealed otherwise, indicating the SCA had little predictive value.
Van Wassenhove W, Foussard C, Dekker SWA, et al. Safety Sci. 2022;154:105835.
Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).
Dekker - van Doorn C, Wauben LSGL, van Wijngaarden JDH, et al. BMC Health Serv Res. 2020;20:426.
This study explored whether combining participatory design and experiential learning supports the adaptation and adoption of TOPplus, which is a communication tool to support and improve communication and teamwork among the operating room team. Adaptation varied amongst the ten participating Dutch hospitals, but all implemented the intervention with all surgical disciplines, and this approach gave teams the opportunity to adapt the intervention to fit their needs and local context. 
Leveson N, Samost A, Dekker SWA, et al. J Patient Saf. 2020;16:162-167.
This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.
Provan DJ, Dekker SWA, Rae AJ. J Safety Res. 2018;66:21-32.
This interview study examined the self-perceptions of safety professionals at an energy company, a high reliability industry often used as a model for patient safety. The results reveal that safety professionals often have contradictory roles within an organization, including relational influence versus formal authority and interpersonal skill versus technical knowledge. The findings highlight the challenge of integrating safety professionals into the larger health care enterprise.
Buljac-Samardzic M, Dekker-van Doorn C, Maynard MT. Group & Organization Management. 2018;43.
Teamwork is a core element of care coordination and safety. Articles in this special issue explore current research and activity on teamwork and teamwork training. Topics include organizational support for a team environment, teamwork as a fall-reduction strategy, interdisciplinary team development, and research design.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
… safety across a variety of industries. … Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537. … DD … S … R … L … N … Woods … Dekker … Cook … Johannesen … Sarter … …
Grundgeiger T, Dekker SWA, Sanderson P, et al. BMJ Qual Saf. 2016;25:392-5.
Interruptions are a common occurrence in health care. This commentary suggests that research about interruptions clearly determine definitions, data collection methods, and processes that are affected to enhance understanding regarding the impact of disruptions on patient safety.
Buljac-Samardzic M, van Wijngaarden JD, van Doorn CMD-. BMJ Qual Saf. 2016;25:424-31.
Safety problems are common in nursing homes and other long-term care facilities, and prior work has shown that safety culture in these settings is generally poor. This validation study found that the Safety Attitudes Questionnaire was a reliable tool for measuring safety culture in nursing homes in the Netherlands. This is a necessary step for much needed research on nursing home safety.
Dekker SWA, Leveson NG. BMJ Qual Saf. 2015;24:7-9.
Highlighting how the systems approach is often misunderstood to ascribe responsibility for failure to the system when things go wrong, this commentary explains that the approach is instead meant to reduce variation and enhance individual responsibility and competence with standard procedures.
Dekker SWA, Hugh TB. BMJ Qual Saf. 2014;23:356-8.
In the context of public reactions to the Francis report, this commentary discusses why the poor conditions were missed and how to prevent failures from recurring once they are identified. The authors advocate for a just culture that balances blame and accountability to address complexities in the health care setting.
Dekker S. Boca Raton: CRC Press/Taylor & Francis Group; 2011. ISBN: 9781439852255.
… and provides practical avenues for its application. … Dekker S. Boca Raton: CRC Press/Taylor & Francis Group; 2011. ISBN: 9781439852255. … SDekkerS Dekker