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.
Skaret MM, Weaver TD, Humes RJ, et al. J Healthc Qual. 2019;41:274-280.
I-PASS, a care transition handoff tool that enhances communication when coordinating patient transfer of care during medical shift changes, has been found to reduce preventable errors associated with handoffs. New pilot study found user-generated patient information and automatically compiled EHR data in the I-PASS format can reduce documentation errors.
This retrospective study of dental patient safety reports in the military health system demonstrated an increase in reported events, which may reflect improvements in safety culture. Wrong-site surgery was the most common adverse event, suggesting the need to enhance safety practices in dentistry.
Ferraro K, Zernzach R, Maturo S, et al. Mil Med. 2017;182:e1747-e1751.
This commentary describes how one hospital established a resident leader to embed quality improvement and patient safety education into daily care processes. The authors review strategies the resident leader championed to drive improvement, including quarterly hospital-wide morbidity and mortality conferences, mock root cause analyses, and a feedback mechanism to respond to resident concerns.
Alexandria, VA: Department of Defense, Office of the Inspector General; February 21, 2014. Report No. DODIG-2014-040.
Examining medication safety challenges unique to the United States military patient population, this report advocates for strengthening policy and medication reconciliation to address concerns, including accidental overdose and misuse of prescription drugs.
West G, Patrician PA, Loan L. Am J Nurs. 2012;112:22-7; discussion 28.
Highlighting the importance of measuring and ensuring adequate staffing levels in hospitals, this commentary describes scenarios drawn from experiences of military nurses that demonstrate how limited staffing can affect nurses, and consequently, patient safety.
Breckenridge-Sproat S, Johantgen M, Patrician P. West J Nurs Res. 2012;34:455-74.
This study found that staff category and patient acuity were associated with medication errors and falls, but total nursing hours and census had no effect. The authors advocate for greater study of organizational factors, particularly at the unit level, to better understand clinical microsystems.
Department of Defense Patient Safety Program; DoD PSP; DoD
This award recognizes outstanding high reliability improvement work in the Military Health System related to themes of healthcare quality, patient safety, improved access, and patient engagement. The process for submitting applications for the 2018 awards is now closed.
This study describes nurses' reasons for medication errors and the barriers to reporting them and then shares experiences with an anonymous shift-based reporting system. The authors advocate for accurate and timely systems to identify medication errors and discuss the importance of a positive safety culture.
This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce medical error through leadership, transparency, teamwork, and communication.
Washington DC: Office of the Assistant Secretary of Defense; Tricare Management Activity: 2011.
This report series discusses activities and achievements of the U.S. Department of Defense's health care program in including culture of safety development, error and near miss report analysis, and medical team coordination. There were 5 editions of the report produced between 2005-2011.
Department of Health and Human Services, Agency for Healthcare Research and Quality, Department of Defense.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. This updated version of the widely implemented program provides new tools to measure its impact, supports increased emphasis on the role of effective communication in team training, and includes a new course management guide. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors. An AHRQ WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented the unnecessary placement of a peripherally inserted central catheter that led to significant complications.
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