The PSNet Collection

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.

Displaying 1 - 7 of 7 Results

Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit.

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Hamilton WL.

Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.

Living with cancer: not talking about medical mistakes.

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Gubar S.

This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.

Noah's story: please listen.

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Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.

This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.

Entire UPMC transplant team missed hepatitis alert.

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Hamill SD.

This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.

Get me out alive.

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Feldman R

In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.

Health for life. Keys to safer hospitals.

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Berwick DM. Newsweek. 2005;146:76-8.

Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.

Lost surgical specimens, lost opportunities.

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PA-PSRS Patient Safety Advisory. Sept 2005;2:1-5.

This article draws from the reporting system in Pennsylvania to discuss lost surgical pathology specimens and recommend a systems-oriented approach to improvement.

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