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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
Van Wassenhove W, Foussard C, Dekker SWA, et al. Safety Sci. 2022;154:105835.
Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).
Leveson N, Samost A, Dekker SWA, et al. J Patient Saf. 2020;16:162-167.
This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.
Dekker SWA, Leveson NG. BMJ Qual Saf. 2015;24:7-9.
Highlighting how the systems approach is often misunderstood to ascribe responsibility for failure to the system when things go wrong, this commentary explains that the approach is instead meant to reduce variation and enhance individual responsibility and competence with standard procedures.

LeCoze JC, Pettersen K, Reiman T, eds. Safety Sci. 2014;67:1-70.

… special issue describes the state of safety science from a range of perspectives, including the meaning of safety … … Kenneth … Petter … Ragnar … Kristine … Torgeir … Sidney … Garth … Ron … Andrew … Andrew … Erik … James … … … Nyce … Le Coze … Wears … Reiman … Aven … G. … K. … W.A … S. … M. … L. … Kenneth Pettersen … Petter G. Almklov … …
Dekker SWA, Hugh TB. BMJ Qual Saf. 2014;23:356-8.
In the context of public reactions to the Francis report, this commentary discusses why the poor conditions were missed and how to prevent failures from recurring once they are identified. The authors advocate for a just culture that balances blame and accountability to address complexities in the health care setting.