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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 - 9 of 9 Results
Makic MBF, Stevens KR, Gritz RM, et al. Appl Clin Inform. 2022;13:621-631.
Many interventions targeting healthcare-acquired condition reduction and prevention target a single condition, rather than the risks of multiple conditions. This proof-of-concept study discusses clinician feedback on a proposed dashboard to enhance clinicians’ management combining the risks of multiple conditions (catheter-associated urinary tract infections, pressure injuries, and falls).
Perspective on Safety November 26, 2019
… Biol Sci Med Sci. 2003;58(9):M813-9. 3. Lavan AH, Gallaher P. Predicting risk of adverse drug reactions in older adults. … J Am Geriatr Soc. 2017;65(12):2559-2561. 5. Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: Implications and … the need for more specialized care and providers? I’m thinking of the geriatric ED [emergency department] and ACE …
This piece describes patient safety risks when caring for frail older patients and summarizes potential approaches for clinicians to minimize this risk.
Heidi Wald
Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as a physician advisor for the Colorado Hospital Association and as a Quality Committee Chair for the American Geriatrics Society. We spoke with her about patient safety concerns when caring for frail older patients.
Banaszak-Holl J, Reichert H, Greene T, et al. J Am Geriatr Soc. 2017;65:2244-2250.
Prior studies have demonstrated that managers have more positive perceptions of safety culture than frontline staff across multiple health care settings. This study demonstrated that staff responses to AHRQ's Nursing Home Survey on Safety Culture were higher for administrators than for clinical staff. The authors call for reporting safety culture results by role rather than by facility.
Mody L, Greene T, Saint S, et al. Infect Control Hosp Epidemiol. 2017;38:287-293.
The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.
Myers JS, Tess A, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.
It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.
Tad-Y DB, Pierce RG, Pell JM, et al. Acad Med. 2016;91:1239-43.
Mortality and morbidity (M&M) conferences are an established learning strategy. This commentary outlines how a hospital designed a new M&M model, implemented it system-wide, and tracked related clinical and educational improvements over a 2-year period.
Pell JM, Mancuso M, Limon S, et al. JAMA Intern Med. 2015;175:856-858.
In this study, allowing hospitalized patients to access their own medical records as a patient engagement strategy did not increase clinician workload or patient worry, but patients did not identify errors on their medication list or better understand discharge. Although enabling patient access to records in real-time did not have adverse effects, it did not appreciably improve patient safety in this modest sample.
Cumbler E, Castillo L, Satorie L, et al. J Nurs Care Qual. 2013;28:304-11.
The seemingly simple act of hand hygiene has proved to be a formidable obstacle in patient safety, as hand hygiene rates remain unacceptably low at many hospitals. This study describes how one hospital reframed hand washing as a social issue at the unit level and used a combination of active leadership and psychological approaches (including immediate feedback) to encourage hand hygiene. The program resulted in a sustained improvement in hand hygiene rates, an accomplishment that has led to a drop in health care–associated infection rates in other studies. The seminal Keystone ICU study used a similar approach—framing infection control as a social issue rather than a disease problem—to successfully reduce catheter-associated bloodstream infections.
Wald HL, Kramer AM. JAMA. 2007;298:2782-4.
The Centers for Medicare and Medicaid Services recently announced that they will no longer reimburse hospitals for costs of care associated with preventable in-hospital complications, including some common nosocomial infections such as catheter-associated urinary tract infections. This commentary discusses the clinical and economic consequences of this policy change for hospitals. While acknowledging that implementation of the rule poses challenges, the authors conclude that the new policy will benefit patients by encouraging hospitals to reduce preventable infections.