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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 - 4 of 4 Results
Phillips EC, Smith SE, Tallentire VR, et al. BMJ Qual Saf. 2023;Epub Mar 28.
Debriefing after clinical events is an important opportunity for critical learning, process improvement, and enhancing team communication. This systematic review of 21 studies synthesized findings regarding the attributes and evidence supporting the use of clinical debriefing tools. While all of the evaluated tools included points related to education and evaluation, few tools included a process for implementing change or addressed staff emotions. The authors include recommendations for clinicians, educators and researchers for teaching, implementing and evaluating clinical debriefing tools.
Tallentire VR, Hale RL, Dewhurst NG, et al. BMJ Qual Saf. 2013;22:864-9.
The discovery of a high medication prescribing error rate among physician trainees in the United Kingdom led to recommendations for developing a standardized prescription chart for hospitalized patients. This study found that both individual physician factors as well as the design of the prescription chart appeared to influence prescribing error rates.
Tallentire VR, Smith SE, Skinner J, et al. Acad Med. 2012;87:792-8.
This study used an error-modeling system initially devised by Dr. James Reason as a framework to describe and categorize observed team-based errors. The four types of errors classified were skill-based slips and lapses, rule-based mistakes, knowledge-based mistakes, and violations.