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.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2022;78:2015-2029.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors
Tchouaket E, Dubois C-A, D'Amour D. J Adv Nurs. 2017;73:1696-1711.
This economic analysis estimated the impact of nurse-sensitive adverse events—including pressure ulcers, falls, medication administration errors, pneumonia, and urinary tract infection—for the Canadian health care system. The authors estimate that these adverse events led to more than 1300 excess hospital days per year, and they advocate for more resources for adverse event prevention in order to reduce costs as well as harm.
D'Amour D, Dubois C-A, Tchouaket E, et al. Int J Nurs Stud. 2014;51:882-91.
Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.
Ott LK, Pinsky MR, Hoffman LA, et al. BMJ Qual Saf. 2012;21:509-18.
This cohort study characterizes the types of emergencies that necessitated a medical emergency team evaluation of an inpatient in the radiology department. A case of an ultimately fatal adverse event that occurred while a patient was being transported from an inpatient unit to radiology is discussed in this AHRQ WebM&M commentary.
A considerable amount of attention has been paid to the issue of physician work hours and patient safety, thanks in part to regulations limiting duty hours for resident physicians. Fatigue has also been demonstrated to be a risk factor for errors among nurses, particularly when nurses work overtime or extended duration shifts. In this analysis, the authors found that among nurses, working voluntary overtime or working more than 40 hours per week were strongly correlated with an increase in self-reported errors, particularly needlestick injuries and medication errors. While legislative efforts have focused on restricting mandatory overtime for nurses, these results raise concern that the widespread practice of taking voluntary overtime shifts could negatively affect patient safety.