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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 - 20 of 23 Results
Adams M, Hartley J, Sanford N, et al. BMC Health Serv Res. 2023;23:285.
Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.
Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.
Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.
Walton MM, Harrison R, Kelly P, et al. BMJ Qual Saf. 2017;26:743-750.
This study elicited patients' reports of adverse events during hospitalization. Researchers found that 7% of hospitalized patients reported experiencing an adverse event and, consistent with prior studies, patients contributed unique contextual data to adverse event reporting.
Collier A, Sorensen R, Iedema R. Int J Qual Health Care. 2016;28:66-73.
This ethnographic study revealed dying patients' and their families' perceptions of iatrogenic harm. Communication-related harms were considered distressing to the patients and their families. These results underscore the importance of maintaining trust in end-of-life care to augment safety.
Harrison R, Walton M, Manias E, et al. Int J Qual Health Care. 2015;27:424-42.
Patient perspectives are critical to inform patient safety efforts. This systematic review identified studies of patient experiences with adverse events. Included studies demonstrate that the types of adverse events patients most often identify are medication errors and suboptimal communication, and that patient demographic characteristics influence the likelihood of reporting these events. Calling for increased use of patient experiences in future studies, the authors suggest that investigations into adverse events are incomplete if patient perspectives are not included. These results demonstrate the ongoing need to enhance patient engagement in safety research. A previous AHRQ WebM&M perspective delves further into engaging patients in safety improvement.
Hor S-Y, Iedema R, Manias E. BMJ Qual Saf. 2014;23:1007-13.
This study used video-reflexive ethnography—a qualitative intervention approach that involves videotaping daily work processes and then using the videos to stimulate further discussion and problem solving—to analyze how clinicians create safe spaces for communication in the busy environment of the intensive care unit.
Wu AW, McCay L, Levinson W, et al. J Patient Saf. 2017;13:43-49.
Based on a series of international expert meetings, this qualitative analysis identified key challenges in error disclosure: policy implementation, patient expectations, confidentiality and legal privilege, aligning disclosure with liability, and documenting and tracking disclosure. These barriers suggest that multiple actions are needed to bolster disclosure efforts. The authors advocate for collaboration between health systems and policymakers, enhanced patient and provider education to foster a blame-free safety culture, and establishment of standard metrics to document and benchmark disclosure across institutions. In a past AHRQ WebM&M perspective, Dr. Albert Wu discussed the importance of disclosing adverse events.
Hor S-Y, Godbold N, Collier A, et al. Health (London). 2013;17:567-83.
Highlighting the value of involving patients in their care, this commentary describes barriers to patient engagement and makes recommendations to improve clinician–patient collaboration.
Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-42.
Physician organizations wholeheartedly support full disclosure following medical errors, and The Joint Commission requires that hospitals disclose unanticipated outcomes of care. This detailed case study discusses a unique incident disclosure process that involved prolonged dialogue between a patient's family and hospital staff over the course of multiple telephone calls and meetings. The initial basis for disclosure was a fatal medication error, but these discussions uncovered other serious errors in this case including flawed communication and delayed recognition of clinical deterioration. Using direct quotations from the patient's wife, this report reinforces the important role that patients and their families can play in quality improvement and patient safety. Medical error disclosure is discussed by Dr. Allen Kachalia in an AHRQ WebM&M perspective.
Iedema R, Allen S, Britton K, et al. BMJ Qual Saf. 2012;21:198-205.
Interviews with patients and family members who had experienced a medical error revealed that patients had considerable insight about how to improve care processes to prevent errors. However, they encountered barriers when trying to provide feedback to clinicians and hospital administrators.
Iedema R, Allen S, Sorensen R, et al. Jt Comm J Qual Patient Saf. 2011;37:409-417.
This Australian study used interviews with clinicians, patients, and families to identify a wide range of barriers to disclosing adverse events. The article provides specific guidance for clinicians, risk managers, and policymakers to promote full disclosure of adverse events.
Iedema R, Jorm C, Wakefield JG, et al. J Lang Soc Psychol. 2009;28.
Open disclosure is an important principle and policy in health care, with varying views on its implementation among providers and varying practices in different countries. This article discusses the broad context of an open disclosure policy and provides an empirical analysis of the impact on clinicians.