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.
Vaughan-Malloy AM, Chan Yuen J, Sandora TJ. Am J Infect Control. 2023;51:514-519.
Hand hygiene adherence is an essential component of patient safety. Using the SEIPS 2.0 model, this study explored clinician perspectives about high reliability in hand hygiene. The 61 respondents identified several barriers associated with aspects of organizational culture, environment, tasks and tools, including frequently empty alcohol-based hand rub dispensers and challenges with the layout of patient care areas.
The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.
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.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10:e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Vandenberg AE, Kegler M, Hastings SN, et al. Int J Qual Health Care. 2020;32:470-476.
This article describes the implementation of the Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) medication safety program at three academic medical centers. EQUIPPED is a multicomponent intervention intended to reduce potentially inappropriate prescribing among adults aged 65 and older who are discharged from the Emergency Department. The authors discuss lessons learned and provide insight which can inform implementation strategies at other institutions.
Ryan S, Ward M, Vaughan D, et al. J Adv Nurs. 2019;75:2085-2098.
Safety briefings increase clinical team awareness of activities. In this systematic review, the authors found that safety briefings have the potential to improve safety culture and may have a positive impact on a variety of patient outcomes.
Ameratunga R, Klonin H, Vaughan J, et al. BMJ. 2019;364:l706.
Recent high-profile incidents in the United States and the United Kingdom have fueled debate on the impact of criminalizing medical mistakes that result in patient harm. This article compares how the United Kingdom and New Zealand respond when patients experience unintentional health care–related harm. The authors emphasize the importance of focusing on resolution and learning to improve patient safety.
Rafter N, Hickey A, Conroy RM, et al. BMJ Qual Saf. 2017;26:111-119.
In this retrospective study, researchers sought to understand the frequency of adverse events across Irish hospitals in the context of recent financial constraints. Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately 12% of cases and contributed to significantly increased costs.
Sabin J, Subbe CP, Vaughan L, et al. Clin Med (Lond). 2014;14:462-7.
Many studies have explored how staffing levels influence safe and reliable patient care. Focusing on physician staffing in acute internal medicine, this review describes the way workload, process timing, patient complexity, service set-up, and team skill mix affect staffing needs.
Rafter N, Hickey A, Condell S, et al. QJM. 2015;108:273-7.
This review discusses chart reviews, trigger tools, and voluntary reporting as approaches to monitor adverse events and explores how lack of a standard method to collect and analyze data can hinder progress in determining trends and learning from reported information.
Schweizer ML, Cullen JJ, Perencevich E, et al. JAMA Surg. 2014;149:575-81.
This analysis found that excess hospital costs are significant for patients who experience surgical site infections in the Veterans Affairs system. The authors highlight how adhering to proven practices to reduce postoperative infections provides an opportunity to enhance safety while decreasing costs.
Vaughan L, McAlister G, Bell D. Clin Med (Lond). 2011;11:322-326.
This survey of physicians about the UK equivalent of the "July effect"—a tradition of nearly 50,000 new doctors starting on the first Wednesday in August—found a high degree of concern for patient care, safety, and training. The authors conclude that there is a need for structural changes.
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
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