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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 - 13 of 13 Results
Griffiths P, Maruotti A, Saucedo AR, et al.  BMJ Qual Saf. 2019;28:609-617.
There is a clear link between nurse staffing ratios and patient safety. This study corroborates the finding that lower registered nurse staffing and higher numbers of patients admitted per nurse are associated with increased rates of in-hospital mortality. The results underscore the importance of adequate nursing to ensure safe acute care.
Griffiths P, Ball JE, Bloor K, et al. Southampton, UK: NIHR Journals Library; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Kamboj A, Spiller HA, Casavant MJ, et al. Pharmacoepidemiol Drug Saf. 2018;27:902-911.
… … Pharmacoepidemiol Drug Saf … Medication errors remain a major source of preventable patient harm . Using data from … and that the rate of such errors increased over time. … Kamboj A, Spiller HA, Casavant MJ, Chounthirath T, Hodges NL, Smith GA. …
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Kamboj AK, Spiller HA, Casavant MJ, et al. Ann Pharmacother. 2017;51:825-833.
Medication errors are common in outpatient settings. This retrospective review of data from the National Poison Data System reveals that rates of medication errors involving cardiovascular drugs are rising. Consistent with prior studies of outpatient adverse drug events, older individuals had the highest rate of medication errors. These results underscore the ongoing challenge of achieving safe outpatient medication use.
Robinson EJ, Smith GB, Power GS, et al. BMJ Qual Saf. 2016;25:832-841.
Patients admitted on the weekend may be at increased risk for complications and mortality. This analysis of a large national database examined variations in outcomes following in-hospital cardiac arrest by day versus night and weekday versus weekend. The investigators found that return of spontaneous circulation for 20 minutes or longer, a positive outcome, was more likely during weekday business hours compared with nights or weekends. Similarly, survival to hospital discharge was worse on nights and weekends. These results are consistent with prior studies that demonstrated worse outcomes for patients admitted to hospitals during nights or weekends. Raising concerns that patients who had in-hospital cardiac arrest on nights or weekends might have been more ill at baseline, a related editorial encourages rigorous evaluation of any staffing changes meant to address the weekend effect.
Schmidt PE, Meredith P, Prytherch DR, et al. BMJ Qual Saf. 2015;24:10-20.
Many patients show physiological signs of worsening for several hours prior to requiring more aggressive interventions and transfer to a higher level of care. Rapid response teams have been widely deployed to address this problem, but this approach is fundamentally reactive rather than proactive and has had mixed results so far. This time series study utilized an electronic physiological surveillance system—a real-time decision support system based on patients' vital signs—embedded within the electronic medical record to provide guidance for clinicians in determining patients at risk for deterioration and optimizing treatment intensity. Implementation of the electronic physiological surveillance system was associated with a statistically significant reduction in mortality for a broad range of diagnoses at both hospitals. The results of this study illustrate the potential of novel information technology approaches for prospectively identifying patients at risk for clinical harm.
Spiller HA, Borys DJ, Ryan ML, et al. Ann Pharmacother. 2011;45:17-22.
… … Ann Pharmacother … Preventing medication errors remains a focus of safety interventions, particularly for high-risk … reported to poison centers over the past decade and found a mean annual increase of 18% over that time period. … therapeutic errors accounted for 68% of the total with a progression from 41% to 78% over the study period. Factors …