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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 - 13 of 13 Results
Ryan L, Jackson D, Woods C, et al. J Adv Nurs. 2019;75:1151-1161.
This review examines international evidence on the role nurses play in implementing intentional rounds. The authors explore areas of impact, including patient satisfaction, falls, and hospital-acquired pressure ulcers, and conclude that benefits have been realized from enhanced rounding practice, but further research is needed. They offer implications for practice and highlight the role of leadership, research, and education in reducing the negative expectations of rounding initiatives.
Ferguson C, Hickman L, Macbean C, et al. J Clin Nurs. 2019;28:2365-2368.
Patient misidentification can result in incorrect diagnosis, treatment, and medication administration. This commentary discusses the practice of auditing patient identification wristbands to assess compliance and accuracy. The authors suggest that technological interventions such as smartphone facial recognition and barcode technologies be considered as strategies to avoid patient misidentification.
Alzyood M, Jackson D, Brooke J, et al. J Clin Nurs. 2018;27:1329-1345.
Patients are being encouraged to speak up about safety concerns as part of broader efforts to engage patients in safety programs. This review of studies of patient engagement in hand hygiene programs found some evidence that patients are willing to raise concerns regarding hand hygiene, especially with nurses, but also identified factors that might inhibit patient willingness to discuss these issues with their providers.
Padula WV, Black JM, Davidson PM, et al. J Patient Saf. 2020;16:e97-e102.
The Centers for Medicare and Medicaid Services (CMS) first implemented a policy of nonpayment for specific hospital-acquired conditions (HACs) in 2008. In 2014, they implemented a value-based purchasing program (the Hospital-Acquired Condition Reduction Program) that reduces reimbursement to hospitals with elevated rates of a range of HACs. The program measures HAC rates by a composite Patient Safety Indicator (PSI90), which includes 10 specific PSIs. This study examined HAC rates after implementation of the reimbursement penalty program at a cohort of academic medical centers. Overall, HAC rates declined over the 2 years following implementation of the program, with only rates of pressure ulcers increasing. Another recent study also found declines in HAC rates associated with CMS nonpayment initiatives, and data from AHRQ has also demonstrated significant reductions in HACs over the past 5 years. Nevertheless, concerns persist about the validity of using PSI for patient safety measurement over time, and other studies have found no effect of reimbursement policies on other HACs that are not included in PSI90 (such as specific health care–associated infections). A past PSNet perspective discussed the effect of pay-for-performance and other financial incentives for patient safety.
Hutchinson M, Jackson D, Wilson S. Nurs Inq. 2018;25:e12225.
Lack of consensus regarding whether some types of health care–acquired harm are unavoidable influences design and implementation of patient safety initiatives. This commentary spotlights concerns that normalizing harm as unavoidable can hinder investigation of incidents.
Gleason KT, Davidson PM, Tanner EK, et al. Diagnosis (Berl). 2017;4:201-210.
In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.
Hayes C, Jackson D, Davidson PM, et al. J Clin Nurs. 2015;24:3063-76.
This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.
Hayes C, Power T, Davidson PM, et al. Nurse Educ Today. 2015;35:981-6.
Interruptions pose a significant safety hazard for health care providers performing complex tasks and increase the risk of errors. This commentary describes a simulated training initiative to help prepare nursing students for experiencing and responding to interruptions during medication administration.