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.
Mishra SR, Haldar S, Khelifi M, et al. AMIA Annu Symp Proc. 2018;2018:1425-1434.
… in safety has been endorsed by The Joint Commission as a National Patient Safety Goal. Prior research has shown that … family engagement in safety efforts. … Mishra SR, Haldar S, Khelifi M, Pollack AH, Wanda P. Must We Bust the Trust?: Understanding …
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
… This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for … used for actual care and led to patient harm and death. … TaverniseS. New York Times. January 15, 2015. … S … Tavernise … S …
Sharp D, Palmore T, Grady C. Infect Control Hosp Epidemiol. 2014;35:307-9.
Engaging patients in health care–acquired infection (HAI) prevention, such as asking providers about hand hygiene compliance, has shown promise. This commentary recommends providing patients with information about infection risks and hospital policies as additional areas to involve patients in reducing HAIs.
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
Hill AC, Miyake CY, Grady S, et al. J Pediatr. 2011;159:783-8.
Controversy exists regarding whether children should be required to undergo an electrocardiogram before participating in competitive sports. This study found a significant rate of diagnostic error among pediatric cardiologists in the interpretation of abnormal screening electrocardiograms.
Alexander KP, Chen AY, Roe MT, et al. JAMA. 2005;294:3108-16.
Treatment of acute coronary syndromes (ACS) benefits from extensive research outlining evidence-based practices for improving the quality of such care. This study discovered that more than 40% of patients presenting with ACS received at least one dose of an antithrombotic medication outside the recommended dosing range. These excess doses lead to greater risks of bleeding; the investigators estimate that 15% of patients experience major bleeding due to these prescribing errors. The findings suggest an alarmingly high rate of potential errors and adverse outcomes for ACS patients. The risks also seem directed at vulnerable populations such as elderly patients with specific comorbidities (eg, diabetes, renal insufficiency, and heart failure). With appropriate increases in utilization of antithrombotic agents for conditions such as ACS, greater attention must focus on safe initial dosing practices to prevent adverse drug events.