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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
White A, Fulda KG, Blythe R, et al. Expert Opin Drug Saf. 2022;21:1357-1364.
Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.
Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;18:e1174-e1180.
Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.
Young RA, Fulda KG, Espinoza A, et al. J Am Board Fam Med. 2022;35:610-628.
Identifying barriers and facilitators of medication safety is a patient safety research priority. In this systematic review characterizing the research on medication safety in primary care, researchers found that the majority of studies focused on high-risk populations (such as older adults with polypharmacy) and measured potential harms (such as potentially inappropriate prescribing or potential prescribing omissions) rather than actual harms.
Mackenzie CF, Shackelford SA, Tisherman SA, et al. Surgery. 2019;166:835-843.
This study evaluated trauma readiness among surgical residents following trauma surgery training and its impact on critical errors. Resident trauma readiness index increased significantly following the training, and training resulted in fewer critical errors committed by residents when compared with practicing surgeons. The trauma readiness index may help identify surgeons who would benefit from additional follow up training.
Lee JL, Dy SM, Gurses AP, et al. J Patient Exp. 2018;5:83-87.
Patient perspectives can identify previously undetected adverse events. This commentary discusses the value of seeking patient insights as an approach to measure medication safety and how such evaluation could affect implementation of meditation safety initiatives. The authors suggest adapting system-oriented approaches to reflect patient-centered concerns.
Mackenzie CF, Garofalo E, Puche A, et al. JAMA Surg. 2017;152:581-588.
Surgeons' technical skills are associated with surgical patient outcomes. This evaluation of an educational simulation intervention found that training procedural skills measurably but variably improved surgical performance. Increased experience with procedures following the training led to residents retaining these skills for up to 18 months. These results demonstrate the critical role of procedure volume in building surgical skill and safety. A related editorial focuses on the subset of learners who did not meet technical proficiency, among whom patient safety problems could occur.
Perspective on Safety May 1, 2015
… should accelerate expertise development and perfection. … Yan Xiao, PhD … DirectorHuman Factors and Patient Safety … J Am Coll Surg. 2005;200:29-37. [go to PubMed] 13. Xiao Y, Schimpff S, Mackenzie C, et al. Video technology to advance …
This piece explores the advantages of using video in clinical practice and health care education to augment safety and quality.
Braun BI, Harris AD, Richards CL, et al. Am J Infect Control. 2013;41:638-41.
This study suggests that frontline health care technicians may be less directly engaged in safety efforts compared with other hospital staff. Since these technicians have frequent direct contact with patients, this finding could have important implications for hospital-acquired infection rates.
Compton J, Copeland K, Flanders S, et al. Jt Comm J Qual Patient Saf. 2012;38:261-8.
In this study, implementation of system-wide training and adoption of the structured communication tool SBAR were associated with challenges in uptake and physician education. However, in situations where SBAR was used correctly, physicians were more likely to be able to make clinical decisions.
FitzGerald M, Cameron P, Mackenzie CF, et al. Arch Surg. 2011;146:218-25.
Accurate initial assessment and resuscitation of trauma patients is critical to ensuring correct treatment and survival, and although standardized algorithms have been developed for initial trauma evaluation, errors are not uncommon. This innovative randomized controlled trial implemented a computerized clinician decision support system (CDSS) to ensure adherence to standardized protocols for trauma resuscitation, and used video capture of trauma resuscitations to assess the effects of the CDSS on patient outcomes. Use of the CDSS resulted in significantly reduced errors, and also reduced morbidity compared to standard treatment. This study demonstrates the utility of a CDSS in a fast-paced, high-acuity environment.
Rosser JC, Lynch PJ, Cuddihy L, et al. Arch Surg. 2007;142:181-6; discusssion 186.
This study evaluated the performance of surgical residents on a training program for laparoscopic surgery, in comparison to their performance on video games and their past experience playing video games. Residents who had played video games extensively in the past demonstrated significantly superior laparoscopic skills, and laparoscopic skills were closely correlated to current video gaming ability. While simulation in surgical training has been extensively evaluated, a recent review did not find evidence for the superiority of any specific type of surgical simulation (eg, video, computer, or cadaver-based). As prior research has demonstrated a high incidence of remediable errors in laparoscopy, video games may prove to be a useful adjunct to simulation training.
WebM&M Case March 1, 2004
… card swipe access and restricted viewing periods. … Colin F. Mackenzie, MD … Professor and Director National Study … of Maryland … References … 1. Mackenzie CF, Hu P F-M, Xiao Y, Seagull JF. Video acquisition and audio system …