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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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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.

Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.
Rieckert A, Reeves D, Altiner A, et al. BMJ. 2020;369:m1822.
This study evaluated the impact of an electronic decision support tool comprising a comprehensive drug review to support deprescribing and reduce polypharmacy in elderly adults. Results indicate that the tool did reduce the number of prescribed drugs but did not significantly reduce unplanned hospital admissions or death after 24 months.
Dixon-Woods M, Redwood S, Leslie M, et al. Milbank Q. 2013;91:424-54.
Ethnographic observations and semi-structured interview data showed that implementation of an electronic health record with prescribing and decision support led to greater oversight of and improvements in specific safety metrics.
Avery AJ, Savelyich BSP, Sheikh A, et al. Qual Saf Health Care. 2007;16:28-33.
Enhanced information technology (IT) has been identified as a key component of improving patient safety, but development and implementation of health care IT systems have sometimes led to unintended consequences. In this study, the authors interviewed 31 health care IT stakeholders, ranging from IT developers to frontline clinicians, to identify priority areas for improving IT in the primary care setting. Interviewees voiced a strong interest in using IT for decision support but were frustrated with a perceived lack of attention to human factors engineering in current IT systems.