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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 - 12 of 12 Results
Smith M, Vaughan Sarrazin M, Wang X, et al. J Am Geriatr Soc. 2022;70:1314-1324.
The COVID-19 pandemic disrupted healthcare delivery and contributed to delays in care. Based on a retrospective matched cohort of Medicare patients, this study explored the impact of the COVID-19 pandemic on patients who may be at risk for missed or delayed care. Researchers found that patients with four or more indicators for risk of missed or delayed care (e.g., chronic conditions, frailty, disability affecting use of telehealth) had higher mortality and lower rates of healthcare utilization, including primary care visits.
Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.
Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.
Pandhi N, Schumacher J, Flynn KE, et al. Health Expect. 2008;11:400-8.
Discontinuity is an unfortunate but inevitable reality of medical care, as no clinician can be available around the clock. This study surveyed geriatric patients to examine patients' perceptions of discontinuity in the outpatient setting. Although a relatively small proportion of patients reported that they would feel unsafe if seeing someone other than their primary physician, those who did report concerns tended to have more complex medical problems. This feeling may be well founded, as a recent study documented that communication between providers caring for the same patient is often poor. The safety effects of discontinuity have been most studied in the hospital, and strategies have been developed to improve the transmission of information between inpatient providers.
Zhan C, Smith SR, Keyes MA, et al. Jt Comm J Qual Patient Saf. 2008;34:36-45.
Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.
Zhan C, Friedman B, Mosso A, et al. Health Aff (Millwood). 2006;25:1386-93.
Medical errors have been estimated to cost the US health care system more than $17 billion per year, but whether those costs are borne by patients, hospitals, or insurers is not clear. This economic analysis used administrative data to identify adverse events during hospitalizations, determine the Medicare payments made for hospital claims, and estimate the excess payments made for hospitalizations in which an adverse event occurred. The analysis revealed that adverse events account for a small but significant proportion of overall Medicare hospital spending. Contrary to a prior study, these data revealed that hospitals generally do not receive additional compensation when an error occurs. The authors argue that both individual hospitals and the health care system stand to benefit economically from improving patient safety.
Zhan C, Smith M, Stryer D. Med Care. 2006;44:182-186.
This Agency for Healthcare Research and Quality (AHRQ)–sponsored study looked at the incidence of accidental iatrogenic pneumothorax (AIP) in patients who underwent certain procedures. They found that AIP occurred most frequently after thoracentesis, but also during other procedures.
Zhan C, Hicks RW, Blanchette CM, et al. Am J Health Syst Pharm. 2006;63:353-8.
The investigators from the Agency for Healthcare Research and Quality (AHRQ) and United States Pharmacopeia (USP) compared MedMarx reports from facilities using computerized prescriber order entry (CPOE) with those utilizing conventional methods of ordering.
Miller MR, Pronovost P, Donithan M, et al. Am J Med Qual. 2005;20:239-52.
This AHRQ-supported study discovered few existing relationships between the Joint Commission on Accreditation of Healthcare Organizations accreditation scores and AHRQ’s Inpatient Quality and Patient Safety Indicators (IQIs/PSIs). Given the increasing focus on public reporting of such information to guide consumers in making health care choices, the investigators sought to determine if current reports of accreditation scores reflect more recent and evidence-based IQIs/PSIs. Discussion includes detailed analyses illustrating the relationships, or lack thereof, between the different systems. While many argue that accreditation and performance measurement capture different aspects of quality and safety, this study suggests a need for greater vigilance in defining how and what to measure if the goal is to provide an accurate representation of quality and safety to the public.
Zhan C, Arispe IE, Kelley E, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;31.
This AHRQ–funded study estimates the national prevalence of adverse drug events by capturing data from outpatient physician visits. Using survey data, investigators report on more than 4 million office visits associated with a diagnostic code for an adverse drug event. Although upward trends over time were not statistically significant, the authors conclude that their findings and methods may offer a mechanism for continued tracking of this important safety concern on a national level.
Zhan C, Correa-de-Araujo R, Bierman AS, et al. J Am Geriatr Soc. 2005;53:262-7.
This AHRQ-funded study illustrates potentially harmful drug-drug and drug-disease combinations that occur in ambulatory care in the elderly population. Solutions are provided for minimizing the opportunities for harm associated with these combinations.
Zhan C, Miller MR. JAMA. 2003;290:1868-74.
Using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this study identified medial injuries from more than 7.4 million hospital discharge abstracts. Investigators determined significant variability in both the need for extended hospitalization and the associated costs depending on the specific injury experienced. Building on past work reflecting data from individual institutions (Classen et al and Bates et al), the authors here share specific estimates for excess length of stay, charges, and mortality due to 18 specific types of medical injuries analyzed in nearly 1000 hospitals across the country. For example, infection due to medical care resulted in more than 9.5 extra hospital days, nearly $40,000 in excess charges, and 4.3% attributable mortality.