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.
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, collaborative initiatives, teamwork, and trigger tools.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Meyer AND, Upadhyay DK, Collins CA, et al. Jt Comm J Qual Patient Saf. 2021;47:120-126.
Efforts to reduce diagnostic error should include educational strategies for improving diagnosis. This article describes the development of a learning health system around diagnostic safety at one large, integrated health care system. The program identified missed opportunities in diagnosis based on clinician reports, patient complaints, and risk management, and used trained facilitators to provide feedback to clinicians about these missed opportunities as learning opportunities. Both facilitators and recipients found the program to be useful and believed it would improve future diagnostic safety.
Ursprung R. Qual Saf Health Care. 2005;14:284-289.
This pilot study evaluated the feasibility of using a safety auditing checklist during daily work in an intensive care unit. Investigators developed a 36-item list focused on errors common to this clinical setting and implemented them into rounds on a regular basis for the 5-week study period. Results suggested the ability to detect a variety of errors while engaging staff in a blame-free fashion to stimulate immediate changes in performance. The authors advocate for greater application of safety and error prevention methods into routine clinical work as a mechanism for ongoing quality improvement.
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