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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 - 13 of 13 Results
Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.
Abujudeh H, Kaewlai R, Shaqdan K, et al. American Journal of Roentgenology. 2017;208.
This review summarizes key principles of high quality care and how they can be applied to augment radiology practice. Recommended safety improvement strategies included plan-do-study-act cycles, change management, and balanced scorecards.
Alkan A, Yaşar A, Karcı E, et al. Support Care Cancer. 2017;25:229-236.
Specific medication classes have been deemed potentially inappropriate for older adults due to high risk of adverse drug events. This medical record review study uncovered significant rates of drug–drug interactions and use of potentially inappropriate medications in cancer patients older than 65, consistent with prior studies. The authors suggest that strategies to improve prescribing in older adults are needed.
Bannan DF, Tully MP. J Clin Pharm Ther. 2016;41:246-55.
Many successful patient safety programs involve the use of bundled interventions. For example, the seminal Keystone ICU project combined a checklist with regular data audit and feedback and efforts to improve safety culture. This systematic review of bundled interventions to prevent prescribing errors and medication administration errors in hospitalized children characterized several types of approaches. The authors ultimately determined that the poor quality of existing literature precludes conclusions about effectiveness.
Wang H-F, Jin J-F, Feng X-Q, et al. Ther Clin Risk Manag. 2015;11:393-406.
A hospital in the People's Republic of China was able to achieve a significant reduction in medication administration errors through a multidisciplinary quality improvement effort. The initiative included organizational measures, information technology interventions, quality improvement tools, and process optimization.
Khoo AL, Teng M, Lim BP, et al. Jt Comm J Qual Patient Saf. 2013;39:205-212.
This study involved nurses, physicians, and pharmacists in a collaborative process to design and implement a high-alert medication list at six Singaporean hospitals. Multiple interventions were implemented to improve safety of these medications, resulting in a significant reduction in adverse drug events.