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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 - 13 of 13 Results
Adapa K, Ivester T, Shea CM, et al. Jt Comm J Qual Patient Saf. 2022;48:642-652.
… improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to … events, including near misses . … Adapa K,  Ivester T, Shea C, et al. The effect of a system-level tiered huddle system on reporting patient …
Glickman SW, Mehrotra A, Shea CM, et al. J Patient Saf. 2020;16:211-215.
Patients' perceptions of care may provide valuable insights for improving safety. Researchers surveyed patients seen in an academic emergency department over a one-year period. They found that patients were able to accurately identify adverse events and near misses, only a small fraction of which were also submitted to an existing incident reporting system.
Hawley KL, Mazer-Amirshahi M, Zocchi MS, et al. Acad Emerg Med. 2016;23:63-69.
This analysis of medication shortages in the emergency department revealed that there have been shortages of high-acuity medications for which no substitute is available. This suggests further investigation into patient safety implications of drug shortages is needed.
Mayer CM, Cluff L, Lin W-T, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.
Teamwork training programs have resulted in some notable successes, but many other attempts have failed to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in durable provider behavior change. In this AHRQ-funded study, the TeamSTEPPS training program was introduced in two intensive care units (one pediatric and one adult surgical), after meticulous preparatory planning that emphasized the utility of the training for frontline care providers, engaged higher-level support for the effort, and established clear metrics for effectiveness. The program resulted in improvement in directly observed team behaviors and measures of safety culture, and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork training interventions in the context of efforts to develop high reliability organizations.
Cheung DS, Kelly JJ, Beach C, et al. Ann Emerg Med. 2010;55:171-80.
Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.
Schulman KA, Berlin JA, Harless W, et al. N Engl J Med. 2002;340:618-626.
Gender, racial, and ethnic disparities in healthcare can affect patient safety and lead to poor outcomes. This study used actors portraying patients to explore the impact of race and sex on physicians’ decision-making about use of cardiac catheterization for chest pain. Analyses indicate that women and Black patients with chest pain were less likely to be referred for cardiac catheterization compared to white men.