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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 - 10 of 10 Results
Enumah SJ, Sundt TM, Chang DC. J Healthc Manag. 2022;67:367-379.
Hospitals that implement quality improvement initiatives improve patient safety but also incur financial expenses related to implementation, sustainment, and reporting. This study used data from the American Hospital Association and Hospital Compare to evaluate the relationship of financial performance and quality in hospitals performing cardiac surgery. The findings indicate hospitals with lower Patient Safety Indicator 90 (PSI 90) scores had poorer financial performance in the following year.
Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.
While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.
Hashmi ZG, Haut ER, Efron DT, et al. JAMA Surg. 2018;153:686-689.
Determining which harms are truly preventable remains an ongoing challenge in the field of patient safety. In a 2016 report, the National Academies of Sciences, Engineering, and Medicine called for achieving zero preventable trauma deaths, but the actual number of preventable trauma deaths in the United States remains unknown. Analyzing administrative data from more than 18 million patients across 2198 hospitals, investigators determined that if low-performing hospitals could provide the same quality of trauma care as high-performing centers, 100,000 lives could be saved over a 5-year period.
Rose J, Evans C, Barleben A, et al. JAMA Surg. 2014;149:926-32.
Using AHRQ Patient Safety Indicators to compare two surgical techniques for abdominal aortic aneurysm repair, this chart review study found that endovascular repair was safer, emphasizing the utility of these measures for characterizing surgical safety despite controversy about their accuracy.
Parsons K, Messer K, Palazzi K, et al. JAMA Surg. 2014;149:845-51.
The increasing technological sophistication of hospital care has led to greater appreciation of the potential safety hazards posed by medical devices. This observational study used the AHRQ Patient Safety Indicators to examine whether the introduction of a new medical device, the da Vinci robot, led to a change in surgical processes or surgeon performance for a specific procedure, radical prostatectomy. The authors found that during initial adoption of the new technique and device, there was an increased risk of unsafe practice compared with the standard method of conducting radical prostatectomy. This finding emphasizes the need to create safety processes and monitoring when novel devices and procedures are introduced, given that voluntary reporting underestimates safety problems related to devices. A recent AHRQ WebM&M perspective discusses the challenges associated with ensuring medical device safety in the complex health care environment.
Camp M, Chang DC, Zhang Y, et al. Arch Surg. 2010;145:1085-90.
Retained surgical instruments are among the most dramatic of medical errors, and are considered never events. Although these errors are rare, prior studies in adults have defined risk factors for retained instruments, which include emergency surgeries and intraoperative changes in the surgical plan. This study examined the problem of retained foreign bodies in pediatric surgery, using cases identified by the AHRQ Pediatric Quality Indicators. Gynecologic surgeries emerged as the only type of surgery significantly associated with an increased risk of retained instruments, and retained foreign bodies were associated with increased hospital length of stay and costs (but not increased mortality). Despite the persistence of this problem, controversy remains around how to prevent such errors.