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.
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
The process of transferring primary responsibility for patient care is commonly referred to as a handoff. Handoffs are inherently dangerous times for patient safety due to discontinuity of providers and care delivery. This book offers health care organizations step-by-step instructions, sample forms, and insights to help standardize the patient transfer process. The book provides tips for implementing the SBAR (Situation-Background-Assessment-Recommendation) method, which has become widely accepted as a signout tool. The Accreditation Council for Graduate Medical Education requires residency programs to address safe handoffs during training. An AHRQ WebMM commentary discussed the dangers of suboptimal handoffs.
Wu HW, Nishimi RY, Page-Lopez CM, et al. Washington DC: National Quality Forum; 2005.
In the 2003 report Safe Practices for Better Healthcare, the National Quality Forum (NQF) recommended 30 practices, one of which emphasized improved communication in the informed consent process. This report builds on that safe practice endorsement by summarizing strategies for rapid and widespread adoption. The report describes experiences from four hospitals that successfully implemented the practice and discusses common barriers and solutions involved. Recommendations are provided to guide health care organizations still striving to meet the requirement for an effective informed consent process.
Robins NS. New York NY: Delacorte Press; 1995. ISBN: 9780385308090.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.
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