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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 42 Results
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;Epub May 29.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
Buetti N, Marschall J, Drees M, et al. Infect Control Hosp Epidemiol. 2022;43:553-569.
Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.
Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.
Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Zuccotti G, Samal L, Maloney FL, et al. Ann Intern Med. 2018;168:820-821.
Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.
Rhee C, Dantes RB, Epstein L, et al. JAMA. 2017;318:1241-1249.
… at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis … In contrast, analysis of claims-based data suggests a significant increase in the incidence of sepsis over time as well as a marked decrease in sepsis mortality and death or discharge …

Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801.

… Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801 . … Deborah … Deverick … Sean … David … Erik … Dale … Janet … Keith … Michael … Evelyn … … … Neil … Donald … John … Trish … Edward … Lisa … Susan … Yokoe … Anderson … Berenholtz … Calfee … Dubberke … Gerding … …
Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.
Hand hygiene adherence is a key target for improving patient safety. This guideline offers an overview of evidence-based strategies to monitor and promote hand hygiene, including resources developed by the Centers for Disease Control and Prevention and the World Health Organization's "5 moments" program. The authors provide detailed practice recommendations to increase hand hygiene compliance as a way to reduce health care–associated infections. The guideline is one of the 2014 infection control compendium updates published in the journal.
Talbot TR, Bratzler DW, Carrico RM, et al. Ann Intern Med. 2013;159:631-635.
Public reporting of health care–associated infection rates serves as a key measure for quality in hospitals. This commentary reveals limitations to using these metrics, such as variation in definitions, and outlines standards to guide the collection and utilization of surveillance data.
Huang SS, Septimus E, Kleinman K, et al. N Engl J Med. 2013;368:2255-2265.
Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This pragmatic, cluster-randomized trial to determine the most effective approach for reducing the rates of MRSA was implemented in 43 hospitals, including 74 ICUs and 74,256 patients. Compared to baseline, modeled hazard ratios for MRSA clinical isolates were 0.92 for those undergoing screening isolations, 0.75 for targeted decolonization, and 0.63 for universal decolonization. Universal decolonization resulted in significantly greater reduction in blood stream infections than the other two studied approaches for infection reduction.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Loren DJ, Garbutt J, Dunagan C, et al. Jt Comm J Qual Patient Saf. 2010;36:101-8.
Patients desire and deserve disclosure of any errors that occur in their care, but fear of malpractice lawsuits is one of many factors that contribute to clinicians failing to disclose errors in a timely and transparent fashion. This survey compared how risk management professionals and physicians responded to simulated error scenarios. The researchers found that while risk managers were more likely to recommend full disclosure of both serious and less serious errors, physicians were more likely to offer an apology to the patient. Apologies may in fact be used as evidence in a malpractice lawsuit under certain circumstances—a 2008 review of "apology laws" found that while "expressions of sympathy" are generally protected from use as evidence, "admissions of fault" are admissible, even when such admissions include an apology. This fact may have influenced the risk managers' advice against apologizing. The tense relationship between error disclosure and malpractice liability is discussed in a PSNet perspective.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Perspective on Safety April 1, 2008
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths. Email to a colleague Digg This Printable View Methicillin-Resistant Staphylococcus aureus Perspective by Gary A.
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths. Email to a colleague Digg This Printable View Methicillin-Resistant Staphylococcus aureus Perspective by Gary A.