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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
Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Qual. 2020;9.
This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.
Prgomet M, Li L, Niazkhani Z, et al. J Am Med Inform Assoc. 2017;24:413-422.
While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.
Cho I, Park H, Choi YJ, et al. PLoS One. 2014;9:e114243.
This study reviewed prescriptions following implementation of a computerized provider order entry system. More than half of examined prescriptions had medication errors, most often related to incorrect documentation of verbal orders. These results add to concerns about unintended consequences of computerized provider order entry.