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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
Jarrett P, Keogh S, Roberts JA, et al. Intensive Crit Care Nurs. 2023;77:103403.
As with all medications, delays in or underdosing of antimicrobials can result in unnecessarily long hospital stays. This study found that discarded antibiotic vials in the intensive care unit (ICU) contained residual drug remaining in the vial (median 3.7% error). This finding suggests patients may not be receiving the full prescribed dose.
Keogh C, Kachalia A, Fiumara K, et al. Jt Comm J Qual Saf. 2016;42:186-194.
This quality improvement initiative found that providing measurement, feedback, coaching, and financial incentives led primary care practices to improve medication reconciliation over time. This suggests that multimodal interventions using traditional quality improvement methods can address longstanding safety issues in primary care.
Freemantle N, Ray D, McNulty D, et al. BMJ. 2015;351:h4596.
This commentary discusses the weekend effect, in which hospital admission on the weekend confers a higher risk for mortality, and proposes increased services on the weekend in order to ensure safe care. The authors note that it is unclear what factors lead to higher mortality on the weekend. Since the weekend effect exists across multiple care settings, examining off-hours staffing more broadly will likely improve patient safety.
O'Dea A, O'Connor P, Keogh I. Postgrad Med J. 2014;90:699-708.
This meta-analysis found that while there is clear evidence that team training had positive effects on knowledge, attitudes, and behaviors, there is little evidence that such improvements persist over time. Studies to date have not demonstrated that team training augments clinical outcomes. The authors call for larger, multicenter, longitudinal studies in order to draw clear conclusions about the impact of such training on safety.
Freemantle N, Richardson M, Wood J, et al. J R Soc Med. 2012;105.
Past studies have described the relationship between weekend care and overall complications, delays in urgent procedures, survival from in-hospital cardiac arrest, and mortality from acute myocardial infarction. Weekend admissions have also been associated with 10% higher odds of death. This study adds to the existing literature by analyzing more than 14 million admissions to the National Health Service Hospitals in England. Investigators found a higher rate of 30-day deaths for weekend admissions compared to midweek ones. Of note, there was a reduced risk of deaths occurring on the weekends themselves; the risk came on subsequent days. The authors highlight the economic tradeoffs that must be considered in determining whether providing equivalent care on weekends is a viable investment of limited resources.