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.
Guo W, Li Y, Temkin-Greener H. J Am Med Dir Assoc. 2021;22:2384-2388.e1.
This study examined the association between patient safety culture (PSC) measured by the Nursing Home Survey on Patient Safety Culture and community discharge of long-term care (LTC) residents. Results show that two domains of PSC- teamwork and supervisor expectations and actions regarding patient safety- are significantly associated with increased likelihood of discharge to a community setting. Focusing on these domains to improve patient safety culture may also increase community discharge rates.
Sloane PD, Yearby R, Konetzka RT, et al. J Am Med Dir Assoc. 2021;22:886-892.
Racial bias and racism are increasingly seen as a critical patient safety issue. In this article, the authors outline the components of systemic racism (structural/institutional, cultural, and interpersonal), how they manifest and affect the long-term care system, and the detrimental impact of systemic racism on Blacks during the COVID-19 pandemic.
Orth J, Li Y, Simning A, et al. Gerontologist. 2021;61:1296-1306.
Nursing home patient safety culture is associated with healthcare quality and patient outcomes. This large cross-sectional study of nursing homes in the United States found that speaking-up behavior and communication openness were associated with a decreased risk of in-residence death among older adults with dementia. This association was strong in nursing homes located in states with higher nursing home nurse staffing requirements.
Ganguli I, Simpkin AL, Lupo C, et al. JAMA Netw Open. 2019;2:e1913325.
Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.
Li Y, Cen X, Cai X, et al. Med Care. 2019;57:641-647.
This cross-sectional study found that nursing homes with higher scores on Nursing Home Survey on Patient Safety Culture performed better in measures of quality and safety. A prior PSNet perspective discussed how to change a safety culture.
Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Med Care. 2017;55:447-455.
The Centers for Medicare and Medicaid Services policy on nonpayment for certain hospital-acquired conditions serves as a strong incentive to prevent adverse events during hospitalization. This observational study examined Medicare's nonpayment policy for conditions such as health care–associated infections. As with prior studies, investigators determined that the incidence of hospital-acquired conditions declined following implementation of nonpayment. For certain conditions, such as catheter-associated urinary tract infections, hospitals with a larger proportion of Medicare patients had greater improvements. The authors note the variation in rates of hospital-acquired conditions and differing magnitude of improvement. They recommend further study to understand how to achieve similar successes in reducing hospital-acquired conditions.
Glance LG, Osler T, Li Y, et al. Med Care. 2016;54:608-15.
The weekend effect, in which patient outcomes are worse outside of usual business hours, is well-documented across multiple care settings. Analyzing administrative data, this study found a higher rate of complications in both urgent and elective surgery on the weekend compared to the weekdays. This finding emphasizes the need to develop and test strategies to enhance safety on evenings and weekends in acute care settings.
Song H, Ryan M, Tendulkar S, et al. Health Care Manage Rev. 2017;42:28-41.
Health care teams are seen as a key patient safety strategy. This mixed-methods study found that better team dynamics was associated with higher work satisfaction for attending primary care physicians. This finding suggests that enhancing teamwork may be one way to address primary care physician burnout.
Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.
This retrospective cohort study applied the American College of Surgeons National Surgical Quality Improvement Program's risk calculator for post-operative complications to ascertain whether it would predict 30-day readmissions. As expected, patients who were predicted to have a high rate of complications were also more likely to be readmitted. The authors suggest that identifying patients at risk for both readmissions and complications prospectively may facilitate targeted intervention.
Glance LG, Dick AW, Osler T, et al. Arch Surg. 2011;146:1170-7.
The Leapfrog Group, a consortium of public and private employers who purchase health care for more than 30 million Americans, strives to improve patient safety through encouraging hospitals to implement the National Quality Forum's safe practices and 3 other key safety interventions (including computerized provider order entry). More than 1200 hospitals nationwide have joined the Leapfrog Group's effort to date. However, this analysis of hospital-level trauma outcomes found essentially no relationship between adoption of the Leapfrog interventions and outcomes for trauma patients. This study's results mirror the findings of a prior study that found no improvement in mortality at Leapfrog hospitals for a broad range of inpatient diagnoses.
Glance LG, Li Y, Osler T, et al. BMC Health Serv Res. 2008;8:176.
As the Centers for Medicare and Medicaid Services will no longer reimburse hospitals for certain preventable complications, hospitals must document if these complications were "present on admission" (POA). This study found that the rate of inpatient complications, as measured by the AHRQ Patient Safety Indicators, was significantly influenced by use of a POA variable, as also found in a prior study.
Stone PW, Mooney-Kane C, Larson EL, et al. Med Care. 2007;45:571-578.
This study examined the relationship between nurse staffing and hospital characteristics and specific patient safety measures, such as nosocomial infection rates and incidence of decubitus ulcers. Lower nurse-to-patient ratios and increased overtime both negatively impacted patient safety and in-hospital mortality, but hospital characteristics were not associated with safety measures. The study confirms and extends the findings of previous studies, which have demonstrated that lower nurse staffing and extended shifts are associated with self-reported errors and increased mortality.