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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 30 Results
Perspective on Safety December 14, 2022
… Van, MHSA … Senior Researcher AIR Crystal City, VA … Sarah E. Mossburg, RN, PhD … Senior Researcher AIR Crystal City, VA 1 …

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

Ellen Deutsch photograph

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Perspective on Safety December 14, 2022
… Cindy Van, MHSA … Senior Researcher AIR Crystal City, VA … Sarah E. Mossburg, RN, PhD … Senior Researcher AIR Crystal City, VA …

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

Michelle Schreiber photograph

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Michelle Schreiber photograph

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Perspective on Safety September 28, 2022
… safety through the use of relationship-based principles, e.g., promoting enhanced caring and listening. Strategies … Care TeamSTEPPS for Office-Based Care Version … Authors … Sarah E. Mossburg, RN, PhD … Senior Researcher AIR Crystal City, VA … …

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

Freya Spielberg

Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC. Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.

Perspective on Safety August 5, 2022
… are commonly used on mobile devices such as smartphones (e.g., an iPhone or Android), tablets (e.g., iPad), and … Dowell, PharmD, PhD … Senior Researcher AIR Columbia, MD … Sarah E. Mossburg, RN, PhD … Senior Researcher AIR Crystal City, VA … …

This piece focuses on the emergence and use of digital applications (apps), app-based products and devices for healthcare, and the implications for patient safety.

Francoise A. Marvel

Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie Health. We spoke with her about the emergence of application-based tools used for healthcare and the patient safety issues surrounding the use of such tools.

Perspective on Safety August 5, 2022
… as the only option for ambulatory care for many clinical (e.g., rural) sites and for various outpatient specialties. 8 … for Patient Safety Research and Practice Boston, MA … Sarah E. Mossburg, RN, PhD … Senior Researcher American Institutes for …

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Perspective on Safety May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

Remle P. Crowe

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Perspective on Safety April 27, 2022
… changes in news media reporting. Traditional media (e.g., newspapers, television and radio) is under intense … Researcher American Institutes for Research Columbia, MD … Sarah E. Mossburg, RN, PhD … Researcher American Institutes for …

This piece discusses the role that media plays in affecting patient safety.

Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. He serves on the Board of Directors for Project Patient Care, and earlier in his career he was a healthcare reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize. We spoke with him about how patient safety efforts are shaped by the media and how the role of media has changed since our original discussion on the role of media in patient safety (published in October of 2009 (https://psnet.ahrq.gov/perspective/conversation-charles-ornstein; https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety)).

Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Perspective on Safety March 31, 2022

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Lee S-H, Phan PH, Dorman T, et al. BMC Health Serv Res. 2016;16:254.
Timely and accurate handoff communication is a critical aspect of patient safety. This survey of hospital staff found that positive perceptions of handoff practices were associated with safety culture, as measured by the AHRQ Hospital Survey on Patient Safety Culture. The authors suggest focusing on improving handoffs as a strategy to enhance safety culture.
Rosen MA, Goeschel CA, Che X-X, et al. Simul Healthc. 2015;10:372-377.
Simulation has been used to improve patient safety in multiple settings. This study examines how simulation can enhance safety leadership. Executive leaders in health care organizations were given the simulated task of addressing patient safety failures, with the goal of improving participants' competency in transparency and safety culture. Qualitative analysis demonstrated widely diverging participant responses. There was a lack of leadership engagement with frontline staff around safety. Participants cited leadership walk rounds and committee participation as possible leadership involvement mechanisms. The authors also noted that participants did not consistently engage patients in their safety strategies. Simulation appears to be a promising leadership education strategy that may uncover gaps in current leadership practices. A PSNet perspective explored how leaders can promote cultural changes to improve patient safety.
Biddison ELD, Paine LA, Murakami P, et al. BMJ Qual Saf. 2016;25:31-7.
This secondary analysis examined the relationship between safety culture and employee engagement. Higher levels of engagement (defined as a positive work-related mindset including dedication and absorption in one's work) was correlated with higher scores on the Safety Attitudes Questionnaire, suggesting that quality improvement work should consider these aspects of workplace culture.