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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 - 7 of 7 Results
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.
Rafter N, Hickey A, Conroy RM, et al. BMJ Qual Saf. 2017;26:111-119.
In this retrospective study, researchers sought to understand the frequency of adverse events across Irish hospitals in the context of recent financial constraints. Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately 12% of cases and contributed to significantly increased costs.
Williams SD, Phipps D, Ashcroft DM. Int J Qual Health Care. 2015;27:297-304.
This study found that hospital pharmacist reporting of medication errors was influenced by behavioral norms, and senior pharmacists were more likely to report errors. These results emphasize the need to bolster safety culture to enhance reporting of adverse events.