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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 - 13 of 13 Results
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174:927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Donohue JM, Kennedy JN, Seymour CW, et al. Ann Intern Med. 2019;171:81-90.
Many people who illicitly use opioids first received those medications in health care settings. This retrospective cohort study found that people who were prescribed opioids in the hospital are more likely to be dependent on them after discharge, especially if they took opioids within 12 hours of leaving the hospital. A PSNet perspective discussed how to address the opioid crisis through a patient safety lens.
Mohan D, Farris C, Fischhoff B, et al. BMJ. 2017;359:j5416.
This randomized controlled trial compared the performance of an educational video game to traditional didactic education via an electronic application for teaching emergency department physicians appropriate triage of trauma patients. Following completion of either the game or traditional education, participants completed several case simulations. Those who completed the game performed better than those receiving traditional education on the simulations, and the effect persisted in a subsample retested 6 months later.
Rhee C, Dantes RB, Epstein L, et al. JAMA. 2017;318:1241-1249.
Early identification of sepsis is essential for initiating appropriate treatment and preventing mortality. In this retrospective study, researchers used clinical data to estimate the incidence of sepsis over time at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis remained stable during this time. Although inpatient mortality due to sepsis declined somewhat, there was no change in the combined outcome of death or discharge to hospice. 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 to hospice. The authors conclude that analysis of clinical data may provide a better understanding of sepsis trends. The accompanying editorial highlights challenges associated with measuring the sepsis incidence and mortality.
Mohan D, Schell J, Angus DC. JAMA. 2016;316:1867-1868.
Heuristics enable experts to build off their experience to arrive at decisions rapidly. However, heuristics can contribute to error and are often discussed in the context of diagnostic missteps. This commentary argues that gaming strategies, which have been proven to improve surgical technique, can hone clinical decision making by helping providers switch from immediate to deliberate mode of reasoning.
Network WG for the CHECKLIST-ICUI and the BR in IC, Cavalcanti AB, Bozza FA, et al. JAMA. 2016;315:1480-90.
Checklists have contributed to some of the most effective patient safety interventions to date, including the landmark Keystone ICU program that nearly eliminated catheter–associated bloodstream infections and the surgical safety checklist that reduced mortality. More recently, checklists have failed to yield improvements in some settings, highlighting that successful programs rely on many external and internal factors beyond checklists. This randomized clinical trial studied the effect of introducing a daily checklist, goal setting, and clinician prompting in intensive care units in Brazil. This robust bundled intervention did not reduce in-hospital mortality. The intervention group showed some improvements in a few process measures, such as use of low tidal volumes, central venous catheters, and urinary catheters, but there was no difference in secondary clinical outcomes. This study adds to the current controversy over the efficacy of checklists for improving patient safety outcomes.
Liu V, Escobar GJ, Greene JD, et al. JAMA. 2014;312:90-2.
This study used national databases to demonstrate that sepsis accounted for more than one-third of all in-hospital deaths among adults. Sepsis care has been the focus of intense quality improvement efforts over the past few years, and these efforts are justified by the high prevalence of this disease.
Kim MM, Barnato AE, Angus DC, et al. Arch Intern Med. 2010;170:369-76.
Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.
Huang DT, Clermont G, Sexton B, et al. Crit Care Med. 2007;35:165-76.
The Agency for Healthcare Research and Quality (AHRQ) recommends assessing employees' perception of the culture of safety on their unit in order to target patient safety efforts. In this study, the investigators surveyed personnel of four intensive care units at a single hospital using the Safety Attitudes Questionnaire, which evaluates perceptions of teamwork climate, stress recognition, and management commitment to safety. The perception of safety culture varied widely across units and across all domains of the survey. As found in prior research, nurses had a more negative impression of the safety culture than did physicians or managers. The authors conclude that analysis of safety culture at the institutional level may result in misleading impressions.
WebM&M Case July 1, 2004
… is a recombinant form of human activated protein C, an endogenous protein that promotes fibrinolysis and … can both lead to unnecessary morbidity and mortality. … Derek C. Angus, MD, MPH … Professor of Critical Care Medicine, …