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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 - 14 of 14 Results
Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.
Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.
Salwei ME, Anders S, Slagle JM, et al. J Patient Saf. 2023;19:e38-e45.
Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.
Hatch D, Rivard M, Bolton J, et al. Jt Comm J Qual Patient Saf. 2019;45:295-303.
The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.
Weiner SG, Baker O, Poon SJ, et al. Ann Emerg Med. 2017;70:799-808.e1.
This pre–post study examined the effect of a change in emergency department opioid prescribing guidelines in Ohio in 2012. The quantity of opioid prescriptions from emergency departments and the duration of opioid prescriptions declined. The authors attribute these declines to the more stringent prescribing guideline and advocate for spreading such policies to improve opioid safety.
France DJ, Throop P, Walczyk B, et al. J Patient Saf. 2008;1:145-153.
This study evaluated the impact of a newly designed children's hospital on patient safety and job function. The investigators begin with a detailed discussion of the contextual factors involved in their hospital redesign, drawing on human factors approaches in safety interventions. They follow by presenting their hospital design process, sharing both unit and floor layouts aimed to ensure family-centered ideals. Results from the 270 clinical faculty and staff surveys suggested that the majority reported a better overall new facility, more efficient information and patient flow, and high ratings for work environment factors such as lighting and equipment availability. However, providers in intensive care settings expressed concern about the negative impact new designs played in team communications, rates of interruptions, and work processes. As perhaps expected, the findings demonstrated many benefits and some unanticipated consequences of the redesign efforts but ultimately reinforced the need for human factors expertise.
Patterson ES, Doebbeling BN, Fung CH, et al. J Biomed Inform. 2005;38:189-99.
Electronic medical records offer opportunities to generate automatic clinical reminders, a feature believed to improve patient care. This study explored barriers to adoption through several observational and survey techniques. Investigators identified ten barriers to effective use, which included workload, time to remove inapplicable reminders, the use of paper forms, accessibility of workstations, and the presence of resident physician and trainees. Discussion involves detailed account of each barrier and how certain future interventions may address them. The authors advocate using this multiprong methodology to identify barriers to effective use of new information technology.