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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 77 Results
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2022;5:15-25.
Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.
Chen Q, Rosen AK, Amirfarzan H, et al. Am J Surg. 2018;216:846-850.
In this study, researchers analyzed 245 intraoperative errors and adverse events reported by physicians through both surgical debriefings and the hospital's incident reporting system. They found a positive association between the presence of intraoperative events and increased postoperative morbidity for patients. In keeping with prior research, the authors conclude that using multiple sources of data provided a more comprehensive picture of safety during surgery.
Mull HJ, Gellad ZF, Gupta RT, et al. JAMA Surg. 2018;153:774-776.
As outpatient surgery becomes more prevalent, attention around related safety concerns grows. Researchers analyzed postprocedure emergency department visits and hospital admissions to better understand factors associated with the safety of outpatient procedures performed within the Veterans Health Administration.
Mull HJ, Graham LA, Morris MS, et al. JAMA Surg. 2018;153:728-737.
Readmissions occur frequently after hospital discharge and may reflect opportunities to improve the quality and safety of care provided during the index admission. Using a modified Delphi process, an expert panel reviewed 30-day postoperative readmissions over a 7-year period for patients who had received surgery within the Veterans Affairs system. The study suggests that more than 50% of postoperative readmissions may be related to the quality of surgical care provided during the index admission.
Mull HJ, Rosen AK, O'Brien WJ, et al. Health Serv Res. 2018;53:3855-3880.
The Veterans Affairs Surgical Quality Improvement Program (VASQIP) and the private sector National Surgical Quality Improvement Program have transformed both safety measurement and quality in surgery. Historically, VASQIP has placed comparatively little emphasis on outpatient surgical safety. This study examined trends in hospital admission within 7 days of all outpatient surgeries performed among veterans age 65 and older in the United States. Researchers found that 16% of these procedures were associated with 7-day admission, higher than what has been observed in younger, healthier patients. Common reasons for admission included surgical, medical, or device complications and inability to secure safe aftercare at home. The authors posit that, while not every admission represents a preventable adverse event, measurement is a critical step toward improving outpatient surgical safety. A recent PSNet interview and perspective explored the evolution of surgical patient safety.
Mull HJ, Rosen AK, Charns MP, et al. J Patient Saf. 2021;17:e177-e185.
This qualitative study asked surgical staff about risk factors for adverse events in outpatient surgery. Respondents identified safety vulnerabilities including patient adherence, equipment, safety culture, and postoperative instructions and care. The authors suggest further research on these topics with regard to outpatient surgery.
Boockvar K, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.
… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Inaccurate medication reconciliation … prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access … on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing …
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. JAMA Surg. 2017;152.
Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.
Chen Q, Rosen AK, Borzecki A, et al. Health Serv Res. 2016;51:2140-2157.
… identify safety events. AHRQ recently restructured PSI-90 (a composite measure containing multiple distinct PSIs) from … PSI-90 measures, use of the harm-based version had a significant impact on pay-for-performance because of … Condition Reduction Program when using the new PSI-90. A past PSNet perspective discussed the impact of …
Bohnen JD, Mavros MN, Ramly EP, et al. Ann Surg. 2017;265:1119-1125.
Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.
Sullivan JL, Rivard PE, Shin MH, et al. Jt Comm J Qual Patient Saf. 2016;42:389-411.
High reliability organizations operate in high-hazard domains with consistently safe conditions. Through individual interviews, investigators determined that staff perceptions of patient safety largely matched their conceptual model of a high reliability health care organization and found two additional characteristics: teamwork and systems approaches to improvement. The authors suggest their model of high reliability organizations can be used to assess organizational reliability.