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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 73 Results
Lainidi O, Jendeby MK, Montgomery A, et al. Front Psychiatry. 2023;14:111579.
Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.
Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;78:458-478.
Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.
Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;78:479-490.
Human factors science focuses on designing systems that make it easy for workers to do the right thing and difficult to do the wrong thing. This narrative review focuses on human factors science in anesthesia. Research is described as it relates to the hierarchy of controls model: design, barriers, mitigations, education, and training.
Blythe R, Parsons R, White NM, et al. BMJ Qual Saf. 2022;31:725-734.
Early recognition of clinical deterioration in patients is often difficult to detect and often results in poor patient outcomes. This scoping review focused on the delivery and response to deterioration alerts and their impact on patient outcomes. Only four out of 18 studies included in the review reported statistically significant improvements in at least two patient outcomes, Authors suggest that workflow and integration of the early warning system model’s features into the decision-making process may be helpful.
Guo L, Ryan B, Leditschke IA, et al. BMJ Qual Saf. 2022;31:679-687.
Unprofessional behavior has been linked to medical errors, surgical complications, and other adverse events. This systematic review summarized the impact of unacceptable behavior related to clinical performance, quality of care, workplace productivity, or patient outcomes. The authors propose that future research should focus on interventions meant to reduce unacceptable behavior.
Dancsecs KA, Nestor M, Bailey A, et al. Am J Emerg Med. 2021;47:90-94.
Alteplase and other thrombolytics are high-alert medications. This study compared error rates of alteplase administration in patients presenting with acute ischemic stroke at either a regional hospital or a Comprehensive Stroke Center (CSC) and found that community hospitals had over a 10 times greater number of errors leading to hemorrhage. The study recommend to put safeguards in place to decrease the risk of alteplase medication administration errors.
Goyal MK, Johnson TJ, Chamberlain JM, et al. Pediatrics. 2020;145:e20193370.
Systemic racism is associated with suboptimal treatment of acute and chronic pain. In pediatric emergency department patients with long-bone fractures, minority children were more likely to receive analgesics and achieve at least a 2-point reduction in pain, but they were less likely to receive opioids and achieve optimal pain reduction.
Mirarchi FL, Juhasz K, Cooney TE, et al. J Patient Saf. 2019;15:230-237.
This single-center study found that Do-Not-Resuscitate (DNR) orders and Physician Orders for Life-Sustaining Treatment (POLSTs) created at hospital admission often do not reflect the true wishes of patients and their caregivers. When queried by study staff, 44% of patients expressed wishes for life-sustaining treatment that differed from their designated code status; this resulted in revocation of the DNR order in more than one-third of patients with a discrepancy. A prior study argued that inaccurate documentation of patient's wishes for end-of-life care should be considered a medical error.
Cook H, Parson J, Brandt N. J Gerontol Nurs. 2019;45:5-10.
This medical record review study of patients admitted to long-term care following a hospitalization found that medication discrepancies were highly prevalent between the patients' home medication lists, hospital discharge summaries, the electronic health record, and the facility's initial physician order sheet. This work highlights the challenges of accurate medication reconciliation.
Ilgen JS, Eva KW, de Bruin A, et al. Adv Health Sci Edu: Theory Pract. 2019;24:797-809.
Uncertainty in complex care situations is a common experience for both trainees and experienced practitioners. This review explores the concept of comfort with uncertainty in medicine and suggests that individual awareness of uncertainty is required to respond to the condition as it occurs. The authors advocate for educational and research strategies to further manage uncertainty in health care.
Molloy MA, Cary MP, Brennan-Cook J, et al. Home Healthc Now. 2018;36:225-231.
Patient utilization of home care is expected to increase with advances in medical care and health technologies. This commentary presents simulation as a promising tool to develop and assess home care staff skills to improve transitions from acute care to home health care.

Wung SF, ed. Crit Care Nurs Clin North Am. 2018;30:179-310.

Care teams rely on a variety of technologies to support safe practice. This special issue focuses on critical care nursing practice and how human factors affect technology use. Articles cover clinical applications of technology and review the role of technologies in critical thinking, medication delivery, and alarm fatigue.
Cook DA, Sherbino J, Durning SJ. JAMA. 2018;319:2267-2268.
This commentary reviews five differences between diagnostic reasoning and patient management reasoning, such as the changing nature of management over time and the team-based nature of the activity. The authors recommend areas of research needed to further understand patient management reasoning.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
MacDougall-Davis SR, Kettley L, Cook TM. Anaesthesia. 2016;71:764-72.
SBAR has been widely implemented to improve communication in health care settings. This simulation study compared the use of SBAR with a newly developed Traffic Lights tool to assess the communication between anesthesia teams in different operating rooms in 12 validated clinical scenarios. The authors found that the new tool yielded more accurate information transfer, took less time to use, and was preferred by the majority of study participants.
Cook DA, Teixeira MT, Heale BS, et al. J Am Med Inform Assoc. 2017;24:460-468.
Infobuttons, a form of clinical decision support, are small icons in the electronic health record that allow users to access online knowledge resources. This systematic review found some evidence that infobuttons may be helpful despite infrequent use. The authors advocate for further research to determine optimal design and implementation of infobuttons in electronic health records.
Pevnick JM, Palmer KA, Shane R, et al. J Am Med Inform Assoc. 2016;23:942-50.
This study measured the potential of using Surescripts electronic pharmacy claims data to prevent admission medication history errors among a sample of 70 older patients on complex medication regimens. Accessing this database would likely have prevented at least 35% of these medication reconciliation errors and nearly half of the most severe errors.
Cook TM, Andrade J, Bogod DG, et al. Anaesthesia. 2014;69:1102-1116.
Reviewing data reported from every public hospital in the United Kingdom and Ireland regarding accidental patient awareness during anesthesia, this study revealed that distress and longer-term harm were prevalent in such incidents despite their short time duration (most lasted less than 5 minutes). The majority of cases were found to be preventable, emphasizing the need to avoid these events.