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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 - 3 of 3 Results
Bapoje SR, Gaudiani JL, Narayanan V, et al. J Hosp Med. 2011;6:68-72.
Patients should improve, not worsen, after hospital admission, and therefore safety interventions such as rapid response teams (RRTs) have been developed specifically to detect and manage unexpected clinical deterioration. This retrospective review of 152 unplanned transfers to the intensive care unit (ICU) at a teaching hospital found that only 15% of unplanned transfers could have been prevented by different management after admission. The most common reason for unplanned ICU transfer was incorrect triage (i.e., the patient should have been admitted directly to the ICU from the emergency department). This study challenges the utility of RRTs in preventing adverse clinical outcomes, and instead identifies the emergency department–inpatient handover as a possible area of focus for quality improvement interventions.
Boyle DJ, O'Connell D, Platt FW, et al. Crit Care Med. 2006;34:1532-7.
This study used a systematic framework for disclosing errors and adverse events to guide providers and facilitate appropriate discussions. The authors provide context to their recommended approach by discussing the scope of the problem in intensive care units, when and how to talk about errors, and the benefits of and problems with doing so. They provide a case example with a detailed dialogue between an attending physician, an intern, and a patient in disclosing news about an error that occurred during her hospitalization. The case illustrates and advocates for the approach recommended both predisclosure and during disclosure. A past study discussed patient and physician attitudes about the disclosure of medical errors.