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.
Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;76:2161-2170.
This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care. Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as difficult patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.
Lin Y-K, Lin C-J, Chan H-M, et al. Injury. 2014;45:83-7.
Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.
Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-62.
Simulation training is being widely implemented in health care, in settings ranging from the emergency department to the operating room. Acting in response to an incident of preventable hypoglycemia, this Israeli hospital conducted a simulation training exercise focusing on teamwork training for nurses, with the goal of improving patient handoffs. The intervention resulted in improvement in nurses' communication of critical information during handoffs.
Youk JH, Kim E-K, Kim MJ, et al. Radiographics. 2007;27:79-94.
The investigators reviewed evidence on ultrasonographic guidance for breast biopsy and provide suggestions on how to minimize sampling error and other problems associated with this diagnostic procedure.