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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 20 Results
Merkow RP, Shan Y, Gupta AR, et al. Jt Comm J Qual Patient Saf. 2020;46:558-564.
Postoperative complications can increase costs due to additional healthcare utilization such as further testing, reoperation, or additional clinical services. This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to estimate 30-day costs resulting from postoperative complications. Prolonged ventilation, unplanned intubation, and renal failure were associated with the highest cost per event, whereas urinary tract infection, superficial surgical site infection, and venous thromboembolism were associated with the lowest cost per event.
Blay E, Barnard C, Bilimoria KY. JAMA. 2018;319:495-496.
This commentary describes a case involving a patient with obstructive sleep apnea who received multiple sedating medications and subsequently had a cardiac arrest while undergoing MRI. The authors explore root causes and provide suggestions for improving the safety of care for patients with obstructive sleep apnea.
Hewitt B, Barnard C, Bilimoria KY. JAMA. 2017;318:2485-2486.
This case report describes an insulin dosing error during hospitalization. The investigation uncovered several root causes, including lack of a standardized medication double-check. The authors note that prompt error disclosure to the patient and family was performed, and the patient required additional monitoring but experienced no further harm.
Engelhardt KE, Barnard C, Bilimoria KY. JAMA. 2017;318:2033-2034.
… system solutions to prevent errors. … Engelhardt KE, Barnard C, Bilimoria KY. Wrong-Site Surgery.  JAMA . …
DeLancey JO, Softcheck J, Chung JW, et al. JAMA. 2017;317:2015-2017.
The Centers for Medicare and Medicaid Services (CMS) recently implemented the star rating system for hospitals as an overall measure of quality and safety. Although studies have found a correlation between the star ratings and clinical outcomes, this study found that high star ratings were more likely to be given to specialty or critical access hospitals. These hospitals are exempt from some of the CMS quality measure reporting requirements, and thus they did not report the same data as lower-rated hospitals. Other studies have also called into question the methodology behind the star rating system.
DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.
Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.
Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.
This case analysis discusses the use of a latex catheter in a patient with a known latex allergy and presents how root cause analysis identified factors that contributed to the error. Recommended corrective actions included educating staff about latex allergies and using a checklist to address communication, documentation, and process weaknesses.
Bilimoria KY, Barnard C. JAMA. 2016;316:1761-1762.
The usefulness of current hospital quality ratings has been called into question. This commentary outlines weaknesses in the Centers for Medicare and Medicaid Services (CMS) star rating system. The authors offer recommendations to CMS to improve their comparison program, including reducing the number of measures tracked, investing more in quality measurement at a national level, and developing a "rate-the-ratings" system.
Rajaram R, Chung JW, Kinnier C, et al. JAMA. 2015;314:375-383.
Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare and Medicaid Services reduces payments to hospitals with the highest rates of these conditions. This analysis sought to assess the association between measures of hospital quality, such as accreditation, and penalties for HACs. Researchers found that accredited hospitals were more likely to incur HAC penalties. Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients. These results add weight to concerns about unintended consequences of pay-for-performance programs leading to widening health disparities and selective treatment, or "cherry-picking" of healthier patients. A related editorial co-authored by two United States Senators calls for including socioeconomic status in the HAC penalty formula.
WebM&M Case December 1, 2014
… University Feinberg School of Medicine Chicago, IL … Cynthia Barnard, MBA, MSJS … Director of Quality Strategies Director … 17. Atlas RM, Clover RD, Carrico R, Wesley G, Thompson M, McKinney WP. Recognizing biothreat diseases: realistic …
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Szekendi MK, Barnard C, Creamer J, et al. Jt Comm J Qual Patient Saf. 2010;36:3-9.
Morbidity and Mortality (M&M) conferences are a time-honored part of medical training. However, these conferences are only rarely used to discuss medical errors or patient safety problems. Even when errors are discussed, learning opportunities may be limited due to lack of a formal mechanism for analysis and follow-up. This article discusses how one academic hospital restructured their monthly M&M conference to focus specifically on patient safety and quality improvement learning objectives. Cases were selected based on voluntary error reports and were presented in a root cause analysis format in an interdisciplinary fashion. Implementation of the restructured conference was associated with improvement in safety culture perception (as measured by the AHRQ Hospital Survey on Patient Safety Culture), and the nursing and pharmacy departments subsequently implemented similar conferences.