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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 - 10 of 10 Results
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Gagliardi AR, Eskicioglu C, McKenzie M, et al. Am J Infect Control. 2009;37:398-402.
This study conducted interviews with surgical division heads and managers of quality improvement and infection control at seven hospitals to highlight thematic strategies for preventing surgical site infections. The authors advocate for a combination of educational initiatives, performance data, explicit accountabilities that trigger action, and engaged champions to succeed in the team-oriented effort.
Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-83.
This AHRQ-funded multicenter prospective study used data from a previously described voluntary reporting system, the Intensive Care Unit Safety Reporting System (ICUSRS), to compare the types and severity of safety problems for medical and surgical ICU patients. Despite differences in the types of patients, the types of errors reported were generally similar between the two groups, with most errors being attributable to training and team system factors (such as communication). Prior studies using data from the ICUSRS have analyzed factors contributing to medication order entry errors and procedural errors.
Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-15.
This study reports the initial findings from a voluntary, Web-based patient safety incident reporting system for intensive care units (ICUs). The system, developed through funding by the Agency for Healthcare Research and Quality (AHRQ), collected data on incidents that could have resulted in patient harm. During the study, more than 2000 reports were filed from 23 participating ICUs. A substantial minority (42%) of incidents led to patient harm, and most had multiple contributing factors, such as deficiencies in training or teamwork. The authors note that the science of incident reporting systems is still in its infancy and recommend that future research should study how to use incident reporting data to improve patient safety.
Thomas EJ; Sexton JB; Lasky RE; Helmreich RL; Crandell DS; Tyson J.
The researchers videotaped neonatal resuscitation teams over 1 year to observe their interaction behaviors and compliance with guidelines. They found correlations between team behaviors and compliance with guidelines and overall quality of care.