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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 - 6 of 6 Results
Wu G, Podlinski L, Wang C, et al. Jt Comm J Qual Patient Saf. 2022;48:665-673.
Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).
Hunter J, Porter M, Williams B. Australas Emerg Care. 2022;Epub Aug 29.
Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation may unfold in the future. Paramedics and emergency medical technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative results indicated the providers were not situationally aware during the simulation.
Imach S, Eppich WJ, Zech A, et al. Simul Healthc. 2020;15.
This case study describes the use of root cause analysis to investigate a critical incident occurring during an emergency medicine simulation scenario, and discusses the importance of these investigations in furthering the training of emergency medicine personnel and instructors.
WebM&M Case April 29, 2020
A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.
WebM&M Case December 18, 2019
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-34.
This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.