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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
Aaron SD, Vandemheen KL, FitzGerald M, et al. JAMA. 2017;317:269-279.
Misdiagnosis can contribute to overuse of unnecessary medication and treatments as well as a delay in appropriate treatment, placing patients at increased risk of harm. This prospective cohort study suggests that asthma may be frequently misdiagnosed in the community setting as a result of inadequate testing for airflow limitations. In 2% of the cases analyzed, a serious underlying cardiorespiratory condition was misdiagnosed as asthma.
Redley B, Bucknall T, Evans S, et al. Int J Qual Health Care. 2016;28:573-579.
Efforts to improve the safety of handoffs have focused on standardizing the signout process. In this mixed methods study, researchers observed 185 anesthetist-to-nurse handoffs from the operating room to the postanesthesia care unit across 3 hospitals. They then conducted focus groups to better understand aspects of safe handoff practices. This work led to the development of a more standardized handoff structure.
FitzGerald M, Cameron P, Mackenzie CF, et al. Arch Surg. 2011;146:218-25.
Accurate initial assessment and resuscitation of trauma patients is critical to ensuring correct treatment and survival, and although standardized algorithms have been developed for initial trauma evaluation, errors are not uncommon. This innovative randomized controlled trial implemented a computerized clinician decision support system (CDSS) to ensure adherence to standardized protocols for trauma resuscitation, and used video capture of trauma resuscitations to assess the effects of the CDSS on patient outcomes. Use of the CDSS resulted in significantly reduced errors, and also reduced morbidity compared to standard treatment. This study demonstrates the utility of a CDSS in a fast-paced, high-acuity environment.
Evans S, Smith B, Esterman A, et al. Qual Saf Health Care. 2007;16:169-75.
The investigators describe an incident reporting intervention that included education on reportable incidents, changes in the process to reduce the fear of reporting, a shorter reporting form, and newsletters to share feedback. They found that this intervention significantly improved reporting.