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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 - 16 of 16 Results
WebM&M Case August 21, 2016
Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.
Patel VL, Kannampallil TG, Shortliffe EH. BMJ Qual Saf. 2015;24:468-474.
Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A Perspective interview with Dr. Pat Croskerry explored the role of cognition in medical error.
Abraham J, Kannampallil TG, Patel VL. J Am Med Inform Assoc. 2014;21:154-62.
The patient safety risks associated with handoffs have been well documented. As a result, multiple investigators have developed standardized tools to improve the quality of information transfer during handoffs. What remains unclear is the extent to which standardizing the handoff process improves patient safety. This systematic review of 36 studies examining the effectiveness of handoff tools found that most tools were not evaluated rigorously and did not specifically assess the effect of standardizing handoffs on patient-level outcomes. Therefore, the authors were unable to reach conclusions regarding the optimal methods for improving the quality of handoffs. Similar problems were noted in studies of checklists, another widely implemented safety intervention, highlighting both the difficulty and the importance of strictly evaluating patient safety interventions.
Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-23.
This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.
Hakimzada AF, Green RA, Sayan OR, et al. Int J Med Inform. 2007;77.
This study describes several instances of near misses that occurred due to patient misidentification, such as physicians being unable to access previous test results because—unknown to them—the patient had been assigned a second medical record number. The investigators used human factors analysis to identify the underlying systems issues that contributed to these errors. Previous studies in adult and pediatric inpatients have also identified patient misidentification as a potential contributor to a large number of errors.
Laxmisan A, Hakimzada F, Sayan OR, et al. IntJ Med Inform. 2007;76:801-811.
This study evaluated factors that jeopardize safe decision-making using ethnographic observation and interviews. Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes for attending physicians. Observed gaps in communication resulted from poor information flow complicated by inherent multitasking, shift changes, and other activities such as documentation time and utilization of computer resources. The authors present typical workflow patterns in the ED and provide a summary of interview responses to illustrate the taxing nature of cognitive overload facing the studied clinicians. They conclude that carefully designed technology can minimize the effect that interruptions and handoffs have on patient safety.
Horsky J, Kuperman GJ, Patel VL. J Am Med Info Assoc. 2005;12.
This case study analyzes a potassium chloride (KCl) dosing error in a system using computerized provider order entry (CPOE). The authors identified problems related to screen results, usability, training, and others. They use their findings to suggest improvements in their hospital’s CPOE system and to analyze CPOE system–related errors more generally.
WebM&M Case June 1, 2005
An AIDS patient prescribed a combination medicine, including a drug she was already taking, narrowly misses being overdosed.
Laxmisan A, Malhotra S, Keselman A, et al. J Biomed Inform. 2005;38:200-12.
Using the concepts of "sharp" and "blunt" ends of practice, this article explores health professionals' differing opinions on biomedical device-related errors. Investigators requested that study participants express their views on events surrounding three true-error scenarios. Analysis of the transcribed responses revealed that interpretation varied widely between groups. While clinicians focused on clinical and human factors, biomedical engineers focused on device-related issues, and administrators emphasized documentation and training. The authors conclude that individual expertise largely mediates an error analysis, as no single interpretation provides a comprehensive view of all contributing factors.