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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 - 10 of 10 Results
Ahluwalia SC, Damberg CL, Silverman M, et al. Jt Comm J Qual Patient Saf. 2017;43:450-459.
… Patient Saf … This systematic review sought to identify a consistently used definition of a high-performing health system . Less than 20% of the … patient safety as an aspect of high performance. In a related editorial, Dr. Peter Pronovost asserts that …
Rose AJ, Fischer SH, Paasche-Orlow MK. JAMA. 2017;317:2057-2058.
Although medication reconciliation is widely advocated to improve medication safety, barriers to implementation persist. This commentary describes strategies to improve the process to ensure patients and care teams have accurate medication lists. Recommendations include involving the patient in reconciliation and clarifying which provider is responsible for the task.
Fischer SH, Tjia J, Field T. J Am Med Inform Assoc. 2010;17:631-6.
Failure to follow up on test results has been linked to missed and delayed diagnoses in the ambulatory setting. Although electronic health records (EHR) hold great promise for addressing this issue, this systematic review found only modest published evidence linking EHR use to improved laboratory test monitoring. This finding corroborates other studies documenting persistent failure to comprehensively follow up abnormal lab tests and radiologic studies despite use of an EHR. The authors conclude that further research will be required to develop optimal test management systems within electronic medical records.
Tjia J, Field T, Garber LD, et al. Am J Manag Care. 2010;16:489-96.
This study reports on the development of standards for laboratory monitoring of high-risk medications (such as anticoagulants) in ambulatory care. Pilot testing revealed that the developed guidelines were not being consistently followed, with infrequently prescribed medications most likely to be monitored inappropriately.
Nuckols TK, Bell D, Paddock SM, et al. Jt Comm J Qual Patient Saf. 2009;35:139-45.
Incident reporting (IR) systems serve as an important mechanism to understand, analyze, and potentially prevent errors in the hospital setting, though their utility has been questioned. This study categorized more than 2200 incident reports into whether they described aberrant care processes, undesirable outcomes, or both. Investigators found that 50% were only process-oriented and that these were more useful than solely outcome-oriented reports because the former helped identify preventability and relevant contributing factors. The authors advocate for hospitals to focus their IR systems on process-driven reports that encourage staff to highlight factors amenable to improvement interventions.
Nuckols TK, Bell D, Liu H, et al. Qual Saf Health Care. 2007;16:164-8.
… filed by nurses, with less than 2% filed by physicians (a problem noted in prior research ). This pattern likely influenced the spectrum of problems reported; only a small proportion of reported incidents related to procedures. A prior commentary proposed a theoretical framework for using …