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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 32 Results
Abraham J, Meng A, Sona C, et al. Int J Med Inform. 2021;151:104458.
Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.
Woeltje KF, Olenski LK, Donatelli M, et al. Jt Comm J Qual Patient Saf. 2019;45:480-486.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Preventable patient safety problems … challenge health care organizations. This report describes a quality improvement intervention to reduce preventable harm in a 15-hospital health system using benchmarks, …
Huang SS, Septimus E, Kleinman K, et al. N Engl J Med. 2013;368:2255-2265.
Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This pragmatic, cluster-randomized trial to determine the most effective approach for reducing the rates of MRSA was implemented in 43 hospitals, including 74 ICUs and 74,256 patients. Compared to baseline, modeled hazard ratios for MRSA clinical isolates were 0.92 for those undergoing screening isolations, 0.75 for targeted decolonization, and 0.63 for universal decolonization. Universal decolonization resulted in significantly greater reduction in blood stream infections than the other two studied approaches for infection reduction.
Loren DJ, Garbutt J, Dunagan C, et al. Jt Comm J Qual Patient Saf. 2010;36:101-8.
Patients desire and deserve disclosure of any errors that occur in their care, but fear of malpractice lawsuits is one of many factors that contribute to clinicians failing to disclose errors in a timely and transparent fashion. This survey compared how risk management professionals and physicians responded to simulated error scenarios. The researchers found that while risk managers were more likely to recommend full disclosure of both serious and less serious errors, physicians were more likely to offer an apology to the patient. Apologies may in fact be used as evidence in a malpractice lawsuit under certain circumstances—a 2008 review of "apology laws" found that while "expressions of sympathy" are generally protected from use as evidence, "admissions of fault" are admissible, even when such admissions include an apology. This fact may have influenced the risk managers' advice against apologizing. The tense relationship between error disclosure and malpractice liability is discussed in a PSNet perspective.
Byrnes MC, Schuerer DJE, Schallom ME, et al. Crit Care Med. 2009;37:2775-81.
Adoption of checklists to standardize and mitigate error-prone processes was popularized in patient safety through a compelling 2007 New Yorker article. The concept was further supported by its resounding success in preventing central-line–associated bloodstream infections. Similar efforts have emerged in surgical settings in which adoption of a specific checklist reduced morbidity and mortality. This study implemented a 14-point checklist in the intensive care unit (ICU) setting to actively engage providers in considering best practices during daily rounds and then evaluated whether the checklist affected practice patterns. While the study did not measure clinical patient outcomes, investigators did demonstrate significant improvements in deep vein thrombosis and stress ulcer prophylaxis, oral care for ventilated patients, electrolyte repletion, initiation of physical therapy, and documentation of restraint orders. The study also demonstrated a two-fold increase in transferring patients out of the ICU on telemetry compared with baseline practice. The authors advocate for use of this cost-effective method to promote best practices in ICU settings.
Henderson KE, Recktenwald AJ, Reichley RM, et al. Jt Comm J Qual Patient Saf. 2009;35:370-376.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This study confirmed that the AHRQ … postoperative deep venous thrombosis (DVT) is best used as a screening tool for identifying preventable DVT cases from … identified nearly all true DVT cases but also identified a significant number of false positives. …
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Garbutt J, Waterman AD, Kapp JM, et al. Health Aff (Millwood). 2008;27:246-255.
… . More than half the respondents reported involvement in a serious error with a similar proportion agreeing that system failures, rather … such as reporting them to a colleague. A past AHRQ WebM&M perspective discussed the experiences and success of the …
Waterman AD, Garbutt J, Hazel E, et al. Jt Comm J Qual Saf. 2007;33:467-476.
This survey sought to evaluate the effects of medical errors on the emotional health of the physician involved in the error. The majority of more than 3000 physicians surveyed had been involved with a serious medical error resulting in patient harm. Physicians reported significant emotional distress as a result, including loss of confidence in their professional skills, insomnia, and decreased job satisfaction. Although prior studies have shown that physicians are generally satisfied with error disclosure, in this study, dissatisfaction with the process of error disclosure, as well as fear of being sued, was associated with greater emotional distress. Very few physicians felt adequately supported by their employer after the incident, a problem also documented in prior research.
Garbutt J, Brownstein DR, Klein EJ, et al. Arch Pediatr Adolesc Med. 2007;161:179-85.
Though medical errors are common in pediatric patients, to date few studies have examined pediatricians' attitudes toward errors. This AHRQ-funded study surveyed pediatric residents and attending physicians regarding their experiences with reporting medical errors. The majority of physicians had direct experience with errors and supported disclosing errors to patients and their parents, but only a minority had disclosed a serious error. Respondents expressed dissatisfaction with current means of reporting errors (eg, incident reporting systems) and expressed a desire for formal training in error disclosure. These findings are similar to those previously reported in physicians caring for adult patients.
Burroughs TE, Waterman AD, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2007;33:5-14.
Prior research has shown that patients are concerned about medical errors and desire full disclosure of errors when they occur. However, patients' perceptions of what constitutes an error may differ from health care providers' perceptions. This study surveyed more than 1600 patients recently discharged from 12 hospitals to determine what patients considered to be an error and to evaluate patients' perception of their safety during their recent hospitalization. Patients defined "error" more broadly than traditional definitions, including such issues as falls, communication problems, and perceived lack of attentiveness by providers. Although nearly all patients felt safe overall, 39% experienced at least one error-related concern during their hospitalization, most commonly due to well-recognized problems such as medication errors. The authors recommend incorporating such patient views into patient-centered safety programs.