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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 26 Results
O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;Epub Oct 31.
Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.
Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.
Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.
Starmer AJ, Spector ND, O'Toole JK, et al. J Hosp Med. 2023;18:5-14.
I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.  
Boggan JC, Shoup JP, Whited JD, et al. J Gen Intern Med. 2020;35:2136-2145.
Remote triage, which can be delivered via telephone, email or video conference, has been linked to potential adverse events. This systematic review evaluated the effects of remote triage systems on healthcare utilization and patient safety outcomes. Of the eight studies identified, three cluster RCTs found high rates of call resolution in local, practice-based triage services compared with regional or national services. Two cluster trials examined the effects of remote triage on mortality, hospitalizations and ED visits; neither reported statistically significant differences indicating increased risk for these patient safety outcomes.
Lewis KA, Ricks TN, Rowin A, et al. Worldviews Evid Based Nurs. 2019;16:389-396.
Simulation is an active learning methodology being used in hospitals to improve patient care.  Results of this systematic review that focused on acute care nurse simulation training and patient safety outcomes indicate that simulation training can be effective for improving patient safety outcomes in this context; the authors note, however, that additional high–quality research is needed to support this field.
O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2018;14:10736.
The I-PASS structured handoff tool intends to reduce errors and preventable adverse events. This article describes the development of the I-PASS Mentored Implementation Guide. The guide was considered by I-PASS sites essential, particularly the sections on the I-PASS curriculum and handoff observations.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Glickman SW, Mehrotra A, Shea CM, et al. J Patient Saf. 2020;16:211-215.
Patients' perceptions of care may provide valuable insights for improving safety. Researchers surveyed patients seen in an academic emergency department over a one-year period. They found that patients were able to accurately identify adverse events and near misses, only a small fraction of which were also submitted to an existing incident reporting system.
Doyle P, VanDenKerkhof E, Edge DS, et al. BMJ Qual Saf. 2015;24:135-41.
Using the Health Professional Education in Patient Safety Survey (H-PEPSS) tool, this study surveyed graduating medical students in Canada regarding their perceptions of patient safety competence. Respondents voiced significant concerns about their knowledge and skills in patient safety. In particular, students expressed concern about the effect of authority gradients on their ability to identify unsafe situations.
Goldstein SD, Papandria DJ, Aboagye J, et al. J Pediatr Surg. 2014;49:1087-91.
… weekend effect , this phenomenon has been demonstrated for a diverse range of diagnoses, including myocardial infarction … pediatric surgical admissions also found evidence of a weekend effect, as patients who underwent a weekend surgical procedure had higher rates of mortality …
Boike JR, Bortman JS, Radosta JM, et al. J Patient Saf. 2013;9:59-67.
Resident physicians may be an underutilized resource for identifying patient safety issues, given their presence at the front lines of care. However, like physicians in general, residents rarely report patient safety events. In this study, an educational effort that attempted to stimulate voluntary error reporting by internal medicine residents achieved modest short-term success, but the vast majority of residents still did not report any errors. No formal feedback was provided after residents reported errors—a common problem with voluntary reporting systems—and the authors acknowledge that the lack of feedback likely explains why the intervention was unsuccessful. A prior study used a financial incentive to successfully encourage residents to report errors and near misses.