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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 - 20 of 26 Results
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Perspective on Safety
October 31, 2023
This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.
This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.
In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace
Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.
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Perspective on Safety
August 30, 2023
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
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Perspective on Safety
April 26, 2023
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
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March 8, 2023
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October 10, 2022
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Perspective on Safety
March 31, 2022
A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.
A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.
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September 13, 2021
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Perspective on Safety
March 1, 2019
This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.
This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.
Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health care system expansion. We spoke with her about the trend of health systems getting larger and more integrated, the risks to patient safety, and ways to mitigate these risks.
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Perspective on Safety
December 22, 2018
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
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Perspective on Safety
March 1, 2017
This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.
This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.
Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.
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Perspective on Safety
January 1, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
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Perspective on Safety
January 1, 2015
While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.
While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.
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Perspective on Safety
September 1, 2013
This piece explores how leaders can promote cultural changes to improve patient safety.
This piece explores how leaders can promote cultural changes to improve patient safety.
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Perspective on Safety
August 22, 2013
This piece explores how safety culture work has evolved over the past decade.
This piece explores how safety culture work has evolved over the past decade.
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Perspective on Safety
December 1, 2011
This piece discusses the multiple, complex causes of falls in hospitalized patients along with prevention strategies.
This piece discusses the multiple, complex causes of falls in hospitalized patients along with prevention strategies.
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Perspective on Safety
May 1, 2011
This piece discusses efforts to ameliorate the impact of errors on providers, including an innovative program to counsel second victims.
This piece discusses efforts to ameliorate the impact of errors on providers, including an innovative program to counsel second victims.
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Perspective on Safety
December 1, 2009
The 1999 Institute of Medicine report highlighted the need for health care providers to address the serious concerns raised about the quality and safety of patient care being provided in our health care organizations. Organizations responded by looking at new ways to fix the system, mostly through the introduction of new technologies and system/process redesign. Advances have been made, but there are still significant opportunities for improvement. Is the barrier poor system or process design, or is it related to addressing basic human behaviors?
The 1999 Institute of Medicine report highlighted the need for health care providers to address the serious concerns raised about the quality and safety of patient care being provided in our health care organizations. Organizations responded by looking at new ways to fix the system, mostly through the introduction of new technologies and system/process redesign. Advances have been made, but there are still significant opportunities for improvement. Is the barrier poor system or process design, or is it related to addressing basic human behaviors?
Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its connection to clinical outcomes and medical malpractice. He is a Professor at the Vanderbilt University School of Medicine, where he is also the Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director of the Vanderbilt Center for Patient and Professional Advocacy, and Director of Clinical Risk and Loss Prevention. We asked him to speak with us about high-risk physicians and malpractice.
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Perspective on Safety
April 1, 2008
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths.
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Methicillin-Resistant Staphylococcus aureus
Perspective
by Gary A.
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths.
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Methicillin-Resistant Staphylococcus aureus
Perspective
by Gary A.
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Perspective on Safety
October 1, 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked.
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked.
An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
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Perspective on Safety
September 1, 2007
There is a slumbering giant, one that carries the potential to transform surgical safety, merely waiting to be awakened and freshened up. I refer to the iconic gathering that so readily evokes the surgical "days of the giants": the traditional surgical morbidity and mortality (M&M) conference.
There is a slumbering giant, one that carries the potential to transform surgical safety, merely waiting to be awakened and freshened up. I refer to the iconic gathering that so readily evokes the surgical "days of the giants": the traditional surgical morbidity and mortality (M&M) conference.
Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School and the Harvard School of Public Health, is an accomplished surgeon and writer and is the recipient of a 2006 MacArthur Fellowship. He is an active clinician at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Dr. Gawande has written two acclaimed and best-selling books: Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. A staff writer for the New Yorker, he also recently completed a stint as a guest columnist for the New York Times. Dr. Gawande is leading the World Health Organization's Second Global Patient Safety Challenge: "Safe Surgery Saves Lives." We asked him to speak with us about professionalism, training, patient safety, and the writing process.
