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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 20 Results
Perspective on Safety June 1, 2019
… State University of New York at Buffalo Buffalo, NY … Rollin J. Fairbanks, MD, MS … Vice President of Quality and Safety, … [go to PubMed] 3. Patriarca R, Bergström J, Di Gravio G, Costantino F. Resilience engineering: current status of …
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.
Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26:381-387.
Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.
Perspective on Safety August 1, 2015
… work in the context of their actual work environment (e.g., observations, task analysis, and other ethnographic … Georgetown University School of Medicine Washington, DC … Rollin J. (Terry) Fairbanks, MD, MS … Director National Center for …
This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Fairbanks RJ, Crittenden CN, O’Gara KG, et al. Acad Emerg Med. 2008;15:633-640.
This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.
Wang HE, Fairbanks RJ, Shah M, et al. Ann Emerg Med. 2008;52:256-62.
This study of closed malpractice claims against prehospital emergency medical services found that clinical management was an infrequent source of malpractice allegations, trailing emergency vehicle accidents and patient handling mishaps.
Fairbanks RJ, Bisantz A, Sunm M. Ann Emerg Med. 2007;50:396-406.
This study used link analysis techniques in observing that face-to-face communication was the most common mode among different provider types in an emergency department. The charge nurse was observed to be the center of communication while interruptions were a common event for both physicians and nurses.
Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23 Suppl 1:41-5.
Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.
Nuckols TK, Paddock SM, Bower AG, et al. Med Care. 2009;46:17-24.
This study discovered that adverse drug events (ADEs) associated with intravenous administration led to increased hospital costs and length of stay, but only in academic centers. Investigators conducted chart reviews for more than 4600 patients in 5 different intensive care units, and present findings from nearly 400 ADEs identified. The majority of events led primarily to temporary physical injuries. In academic settings, the events were associated with more than $6600 in costs and a 4.8 day longer length of stay. The most notable finding was the lack of such differences in nonacademic settings. The authors discuss the differential findings in academic versus nonacademic settings, including how the limitations of their study design may have contributed.
Fairbanks RJ, Caplan SH, Bishop PA, et al. Ann Emerg Med. 2007;50:424-432.
This study used simulated resuscitation scenarios and found that a confusing user interface limited paramedics' ability to properly use two common defibrillator models. A related editorial discusses the challenge of uniting patient safety principles and usability.