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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 - 19 of 19 Results
Ashfaq HA, Lester CA, Ballouz D, et al. JAMA Ophthalmol. 2019.
This study examined the concordance between structured medication lists in the electronic health record and unstructured physician progress notes for antibiotic medications being used to treat keratitis, an eye infection. Researchers found that 23% of prescribed medications differed between the progress note and the structured medication list, highlighting the need for and the challenges in conducting medication reconciliation.
Kachalia A, Sands K, Van Niel M, et al. Health Aff (Millwood). 2018;37:1836-1844.
Health care systems have implemented communication-and-resolution programs (CRPs) to respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error disclosure, investigation into the cause, an apology, and early compensation. Some systems have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that CRPs will increase malpractice costs has limited widespread implementation. Investigators analyzed malpractice costs at four hospitals that implemented CRPs compared with matched control hospitals. Communication-and-resolution programs had either a positive or neutral effect on all metrics including new claims rate, paid claims rate, and total liability costs. This analysis is the most robust to date supporting CRP programs as previous studies have lacked a control group. A previous PSNet interview with Michelle Mello discussed other intersections between patient safety and the law.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.

… and frontline program implementation barriers . … Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161. … Di Tommaso … … Caldwell … Hignett … Ives … Fray … McKeown … Tapley … Woodward … Bowie … Jahn … Jun … Canham … Altuna-Palacios … …
Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541.
… to learn from failure and develop a culture of safety . … Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541. … S. … WoodwardS. Woodward
Hignett S, Lang A, Pickup L, et al. Ergonomics. 2018;61:5-14.
Barriers to achieving safe, high-quality health care are well known. This study described the myriad challenges faced by the National Health Service (NHS) in its quest to provide optimal patient care. The authors suggest that the NHS lags behind other safety critical industries in applying human factors principles.

Albarran J, Scholes J, eds. Nurs Crit Care. 2015;20(4):167-220.

… … A. … T. … P. … H. … N. … P. … T. … A. … L. … H. … C. … S. … C. … J. … Albarran … Scholes … Baid … Hargreaves … Bower … … Richardson … Shaughnessy … Svenningsen … Westgate … Woodward … Jackson … Jackson … J. Albarran … J. Scholes … H. … … L. Shaughnessy … H. Svenningsen … C. Westgate … S. Woodward … C. Jackson … J. Jackson …
Sage WM, Gallagher TH, Armstrong S, et al. Health Aff (Millwood). 2014;33:11-9.
Communication-and-resolution programs continue to face challenges to implementation despite their demonstrated value. This commentary recommends policy adjustments for legal, payment, and peer review protection to address barriers to implementing such programs and optimize their widespread adoption.
Health Aff (Millwood). 2014;33:6-66.
… … JS … RC … T. … J. … A. … D. … B. … T. … DA … J. … AC … S. … Etchegaray … Ottosen … Burress … Sage … Bell … Gallagher … … Bouwmeester … Dunlap … Gallagher … Hyman … Gale … Woodward … Armstrong … T. … B. … H. … JM Etchegaray … MJ … … T. H. Gallagher … DA Hyman … J. Gale … AC WoodwardS. Armstrong …
Bell SK, Smulowitz PB, Woodward AC, et al. Milbank Q. 2012;90:682-705.
Some hospital systems have employed a disclosure, apology, and offer strategy for medical errors, with the University of Michigan program being the best described. This model includes full disclosure of adverse events, appropriate investigations, implementation of systems to avoid recurrences, and rapid apology and financial compensation when care is deemed unreasonable. Researchers for this study interviewed key stakeholders and found strong support for more widespread implementation of this model, despite a lack of generalizable data. Benefits for both the liability system and patient safety were discussed, along with substantial challenges to implementation. However, none of the barriers described were felt to be insurmountable. Dr. Albert Wu discusses adverse event disclosure and apologies in an AHRQ WebM&M perspective.
Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-97 1 p following 497.
This narrative review provides a broad perspective on the current understanding of medical errors and the evidence behind commonly adopted prevention strategies. The authors then highlight a series of recommendations to improve patient safety.