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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 - 17 of 17 Results
Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30:804-811.
This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.
Bailey E, Dungarwalla M. Prim Dent J. 2021;10:89-95.
Research into patient safety culture in primary dental care remains limited. This commentary provides an overview of patient safety in dentistry and tools to develop a robust patient safety culture, including human factors and supporting second victims.

Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.  

The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).  
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Clough S, Handley P. Br Dent J. 2019;227:311-315.
Assumptions, communication barriers, and implicit biases can compromise the care of patients with disabilities. This commentary discusses the presence of diagnostic overshadowing when providing dental services to patients with learning disabilities. The authors provide indications of pain and other behaviors clinicians should recognize to help with diagnosing conditions in this vulnerable population.
Plessas A, Nasser M, Hanoch Y, et al. J Dent. 2019;82:38-44.
This randomized simulation study examined the performance of dentists on a clinical diagnostic task—interpretation of dental radiographs with and without time pressure. Dentists identified abnormal findings more frequently when they did not feel time pressure, suggesting that time pressure adversely impacted their diagnostic acumen.
Stocks SJ, Donnelly A, Esmail A, et al. BMJ Open. 2018;8:e020952.
Adverse events reported by patients are often different and more expansive than safety hazards identified by health care providers. Researchers elicited adverse events from a nationally representative sample of British outpatients. About 8% of patients reported an adverse event, which were frequently problems with medications, accessing care in a timely way, and diagnostic errors.
Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Br Dent J. 2018;224:733-740.
This Delphi study aimed to identify expert consensus on never events in dentistry. The resulting list of 23 events includes medication errors, retained objects, and wrong patient and wrong procedure events across diagnostic and treatment activities and is consistent with existing never events in medicine.
Black I, Bowie P. Br Dent J. 2017;222:782-788.
This study describes a Delphi consensus process for identifying never events for dentistry. Recurring themes included infection control, safe prescribing, and documentation of medical history, consistent with medical never events. A previous PSNet perspective examined patient safety issues unique to dental care and strategies to reduce risks.
Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens A, et al. J Patient Saf. 2021;17:381-391.
Although research has worked to better understand safety issues associated with ambulatory medical care, little is known about safety in dentistry. Investigators analyzed 40 articles describing near misses or adverse events in ambulatory dental care and found a wide variation in the frequency of patient safety incidents across studies. They suggest that more rigorous epidemiological studies are needed to accurately quantify safety events and contributing factors in outpatient dental practice.
Bailey E, Tickle M, Campbell S, et al. BMC Oral Health. 2015;15:152.
This systematic review of patient safety in dentistry found scant evidence for effective patient safety approaches, with the exception of surgical safety checklists, which were successful in preventing wrong tooth extractions. Further research is needed to characterize patient safety in dentistry and implement effective interventions.