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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 26 Results

Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.

Surgery requires specialized approaches to understand and prevent failure. This special issue features the work of multidisciplinary research teams that explored human factors and ergonomic concerns in the operating room that affect communication between robotic-assisted surgery teams, physical resilience of teams, instrument design and use, and poor implementation of briefings as improvement opportunities.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Dean J, Clarkson J, eds. Future Hosp J. 2018;5:145-187.
The systems approach has long been heralded as a key element to safe patient care. Articles in this special issue explore techniques to engage clinicians and leadership in supporting a systems engineering philosophy to optimize safety improvement efforts.

Wung SF, ed. Crit Care Nurs Clin North Am. 2018;30:179-310.

Care teams rely on a variety of technologies to support safe practice. This special issue focuses on critical care nursing practice and how human factors affect technology use. Articles cover clinical applications of technology and review the role of technologies in critical thinking, medication delivery, and alarm fatigue.

Hamilton DK, ed. Crit Care Nurs Q. 2018;41(1):1-92.

Systems and space design are important considerations for safe care delivery. This special issue explores how the built environment can affect safety in intensive care units (ICUs). Articles explore topics such as infection prevention, decentralization of nursing work areas, information flow, and nurse perception of how design features in ICUs affect their ability to care for patients.
Waller MJ. Current problems in pediatric and adolescent health care. 2015;45:378-81.
Applying principles from other fields, such as aviation and nuclear power, to patient safety efforts can help generate sustainable improvements. Articles in this special issue explore how organizational behaviors, human factors, and resilience engineering can uncover risks and enhance system performance in pediatrics.

Albarran J, Scholes J, eds. Nurs Crit Care. 2015;20(4):167-220.

Nurses have a key role in patient safety and advocacy in critical care settings. Articles in this special issue explore the impact of interruptions on nursing care, ward rounds as an opportunity for checklist use, and the importance of integrating safety concepts into nursing education.

Rolston JD, Han SJ, Parsa AT, eds. Neurosurg Clin N Am. 2015;26(2):143-322.

This special issue covers elements of safe care delivery in neurosurgery and features articles exploring the use of simulation, checklists, and the Plan-Do-Study-Act cycle in designing safety and quality improvement initiatives for this setting.
Agency for Healthcare Research and Quality; AHRQ.
This issue covers two successful initiatives to prevent alarm fatigue: the implementation of a 24-hour pulse oximetry monitoring and a series of interventions to reduce alarms in a cardiac unit. The innovation profiles are accompanied by tools used to help hospitals improve alarm safety.
Hamilton DK, Stichler JF, eds. HERD. 2013;7(suppl):1-154.
Articles in this special supplement draw from AHRQ-funded efforts to reveal how designing around space and human factors can reduce the spread of health care–associated infections. Design interventions described include air filtration systems, decontamination of water sources, and antimicrobial surfaces.

Staender S, ed. Best Pract Res Clin Anaesthesiol. 2011;25(2):109-304.  

This special issue explores safety in anesthesia, including safety culture, incident reporting, and handoffs.

Qual Saf Health Care. 2010;19(suppl 3):i1-i79.  

This special issue contains articles discussing human factors and ergonomics in health care simulation, information technology use, hospitals, and home care to reveal opportunities for safety improvement.

Pearlman MD, ed. Clin Obstet Gynecol. 2010;53(3):471-585.  

This special issue provides articles that discuss leadership roles, human factors, risk management, and data collection concepts that promote patient safety.

Simmons D, ed. Crit Care Nurs Clin North Am. 2010;22:161-290. 

Articles in this special issue discuss safe practices, effective staffing, teamwork, and event analysis to enhance patient safety in the critical care setting.