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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
Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;31:670-678.
People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
Sands K, Blanchard J, Grubbs K, et al. Jt Comm J Qual Patient Saf. 2021;47:327-332.
This article describes the development of the Universal Protection Framework, which builds upon traditional infection prevention practices and consists of four domains (infection prevention, access control, distancing, and patient flow) supported by communication and education. The framework was implemented in one large health system with high levels of compliance, particularly for handling of personal protective equipment (PPE), cohorting of COVID-19 patients, facility access controls and employee exposure monitoring.
Medicine S for M-F, Bernstein PS, Combs A, et al. Am J Obstet Gynecol. 2017;217:B2-B6.
… … Am J Obstet Gynecol … Checklists are considered a key tool for improving communication and safety in risky, … of checklists, design elements to consider when developing a checklist, and strategies to implement checklists. …
D'Alton ME, Friedman AM, Smiley RM, et al. J Obstet Gynecol Neonatal Nurs. 2016;45:706-717.
Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.
Perlin JB, Mower L, Bushe C. J Healthc Qual. 2015;37:173-188.
… to harm associated with its use. This commentary describes a comprehensive analysis that identified risks related to … delivery and recommends solutions to enhance its safety. … Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing …
Clark SL, Meyers JA, Frye DR, et al. Am J Obstet Gynecol. 2012;207:441-5.
This analysis of more than 200,000 normal births found that the most common near misses (medication errors and patient identification errors) were easily preventable and had low potential for harm. In contrast, near misses involving physician responsiveness and decision-making were rare, but potentially much more harmful to patients.
Jha AK, Perlin JB, Kizer KW, et al. N Engl J Med. 2003;348:2218-27.
… … N Engl J Med … This study demonstrated the impact of a system-wide reengineering initiative on performance in the … attributed to the use of information technology systems, a model for integration of patient care services, and … care systems and the business case for quality and safety. A leader in these arenas, the VA has also developed …