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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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Harrisburg, PA: Pennsylvania Safety Authority; 2020.

Time pressure can negatively impact critical thinking, information gathering, and communication abilities. This tool builds teamwork and decision-making skills by testing participants as they work through a time-delimited scenario with a sick child to gather clues and determine a diagnosis. 
Kukielka E. Patient Saf J. 2020;2:48-56.
Prior research conducted in the United Kingdom found that obesity is a contributing factor in medical errors and near misses, often due to inadequate equipment. This study used data from Pennsylvania’s statewide patient safety reporting system to characterize safety events related to monitoring and patient care for patients who are obese. From 2009-2018, 107 events were identified; nearly half of events involved MRI or CT scanners and one-quarter involved stretchers. Nearly 75% of the identified events resulted in a delay in care and 41% resulted in temporary harm (e.g., falls, pressure injuries, skin tears, abrasions). The authors summarize the literature on best practices to prevent safety events in patients who are obese, such as alternative approaches to measuring weight and girth and increasing the availability and use of alternative equipment.