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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 32 Results
Santhosh L, Lyons PG, Rojas JC, et al. BMJ Qual Saf. 2019;28:627-634.
This mixed-methods study combined survey data from resident physicians with a comparison of process maps from three academic medical centers to assess handoffs from intensive care units to medical wards. The vast majority of survey respondents could recall at least one adverse event related to suboptimal handoff communication between these settings, and review of the process maps revealed safety gaps in existing processes.
Matern LH, Farnan JM, Hirsch KW, et al. Simul Healthc. 2018;13:233-238.
Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.
Pincavage A, Dahlstrom M, Prochaska M, et al. Acad Med. 2013;88:795-801.
When resident physicians leave their primary care clinic at graduation, their patients are vulnerable to adverse events. This internal medicine residency program created an enhanced handoff system that improved continuity, increased appropriate test follow-up, and demonstrated a trend toward reduced hospital and emergency department visits after the care transition. A WebM&M commentary highlighted risks that breaches in continuity pose to outpatients.
Wray CM, Chaudhry S, Pincavage A, et al. JAMA. 2016;316:2273-2275.
Research suggests that standardization, dedicated space, and supervision improve resident handoffs, but less is known about how these best practices are implemented. Investigators surveyed residency program directors and found significant variation in the implementation of recommended handoff practices and educational strategies.
WebM&M Case April 1, 2016
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.
Farnan JM, Gaffney S, Poston JT, et al. BMJ Qual Saf. 2016;25:153-8.
This simulation study challenged medical students to identify patient safety hazards in a hospital room. Students demonstrated a wide range of accuracy in identifying hazards, with fall risk most likely and pressure ulcer risk least likely to be identified. This finding shows the utility of simulation in patient safety education.
Tanksley AL, Wolfson RK, Arora V. JAMA. 2016;315:603-4.
Clinicians often feel pressured to work while sick or fatigued because of cultural and system factors, including fear of failing colleagues or patients. Exploring findings from a previous study on presenteeism, this commentary spotlights the need for health care organizations to discourage clinicians from working while ill which poses risks to patients. The authors recommend strategies and policies to address this problem, including promoting professionalism that conveys physicians must be healthy enough to provide patient care.
Weinstein DF, Arora V, Drolet BC, et al. New England Journal of Medicine. 2013;369.
… by Dr. Debra Weinstein, the discussion featured Dr. Vineet Arora, Dr. Eileen Reynolds, and surgical resident Dr. Brian … of their overnight experiences. A recent AHRQ WebM&M perspective and interview also discussed the potential …
Greenstein EA, Arora V, Staisiunas PG, et al. BMJ Qual Saf. 2013;22:203-9.
Although much research on effective handoffs has emphasized the responsibility of the sender (the clinician transmitting information), this study evaluated the behavior of clinicians receiving handoffs and found that most clinicians did not engage in active listening behaviors that could improve the quality of information transmission.
Shea JA, Willett LL, Borman KR, et al. Acad Med. 2012;87:895-903.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.
WebM&M Case May 1, 2012
Inadequate signout to the members of the night float team prevented them from appreciating a patient's mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay.