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Patient Safety Network

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 - 4 of 4 Results
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    • 50 Years of Inquiries in the National Health Service.
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    • Polit Q. 2019;90:177-342.
    The National Health Service strategy of publishing their inquiries into systematic poor care in the health service is a model of transparency. Articles in this special issue summarize this legacy and the learning that has been realized by the process. The authors discuss high-profile inquiries, quality of the investigations, and the need for the work to result in sustainable change.
    Medication-administration errors in an urban mental health hospital: a direct observation study.
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    • Cottney A, Innes J. Int J Ment Health Nurs. 2015;24:65-74.
    In this prospective observational study at a psychiatric hospital, errors were identified in 3% of medication administration episodes, with omission being the most common error type. As in prior studies, interruptions and higher patient volume were associated with increased risk of mistakes.
    Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.
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    • Amaral ACK-B, Barros BS, Barros CCPP, et al. Am J Respir Crit Care Med. 2014;189:1395-401.
    This study revealed that cross-coverage, in which physicians care for patients they have learned about through handoffs, was associated with lower mortality in the intensive care unit. This finding counters persisting concerns about harm related to discontinuity of care. The authors suggest that an independent assessment by a second physician may mitigate cognitive errors.
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