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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 - 8 of 8 Results
Schulson LB, Novack V, Folcarelli PH, et al. BMJ Qual Saf. 2021;30:372-379.
This single-site retrospective cohort found that vulnerable populations (defined by race/ethnicity, insurance status, and limited English proficiency) were generally not at increased risk of patient safety events. However, stratified analyses comparing events identified via automated versus voluntary incident reporting systems found voluntary systems may undercount events in some racial/ethnic populations.
Horng S, Joseph JW, Calder S, et al. JAMA Netw Open. 2019;2:e1916499.
The adoption of electronic health record (EHR) systems has led to unanticipated patient safety concerns, such as duplicate orders for tests and medications. This study found that the implementation of a visual aid within the computerized provider order entry (CPOE) system to flag duplicate orders was associated with a 49% decrease in duplicate laboratory orders and a 40% decrease in radiology orders. The authors did not find a decrease in duplicate medication orders. A previous WebM&M commentary describes an adverse event related to duplicate medication orders.
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.
Law AC, Stevens JP, Hohmann S, et al. Crit Care Med. 2018;46:1563-1569.
Inadequate nurse staffing in hospitals leads to increased morbidity and mortality. Two proposed explanations are that nurses provide surveillance and reassessment, which are particularly important for seriously ill patients, and that inadequate staffing leads to missed nursing care. This retrospective cohort study assessed the impact of a 2016 Massachusetts law that mandated minimum nursing ratios in intensive care units. Mortality and complication rates did not change after the law's passage, nor did they differ from states without staffing ratio mandates. Nurse staffing was not substantially higher in Massachusetts after the mandate when compared with other states. Two accompanying editorials highlight the challenges of measuring and promoting appropriate nursing care, which authors argue cannot be simply defined with a staffing ratio. A PSNet perspective and a WebM&M commentary further explore the safety risks of missed nursing care.
Etzioni DA, Wasif N, Dueck AC, et al. JAMA. 2015;313:505-11.
Similar to another study published in the same issue of the Journal of the American Medical Association, this retrospective study found no association between participation in the National Surgical Quality Improvement Program and surgical outcomes over time. This study examined 3 and a half years of data from the University HealthSystem Consortium, which represents a large cohort of academic medical centers.