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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
Turner K, Staggs V, Potter C, et al. BMJ Qual Saf. 2020;29:1000-1007.
Fall prevention remains a patient safety priority. This article describes how fall prevention strategies are being implemented and operationalized across 60 hospitals in the United States. While many hospitals employed recommended strategies identified, implementation was suboptimal at times – for example, interdisciplinary fall committees were common but rarely included physicians.
Mullan J, Burns P, Mohanan L, et al. Australas J Ageing. 2019;38:e135-e141.
Medication-related adverse events resulting in hospital admission were three times as common among older adults with dementia compared to older patients with intact cognition. A WebM&M commentary discussed an incident involving an elderly patient who experienced an adverse drug event requiring hospital readmission.

Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.

… eds. Ergonomics. 2018;61:1-161. … Di Tommaso M … S. … G. … D. … M. … F. … I. … I. … G. … R. … T. … A. … S. … C. … E. … F. … J. … KR … E. … T. … CP … JT … YS … YH … HL … CY … …

Altmiller G, Dolansky MA, eds. Nurse Educ. 2017;42(5S suppl 1);S1-S52.

Patient safety and quality improvement competencies are developed through interprofessional, interactive engagement. Articles in this supplement provide research and insights from a nursing competency development program and discuss successes associated with curriculum integration, implementation science application, and simulation as an educational strategy.
Scott IA, Hilmer SN, Reeve E, et al. JAMA Intern Med. 2015;175:827-34.
Polypharmacy in older patients is a predictor of medication errors. However, deprescribing—stopping or reducing medicines in a patient's drug regimen—can introduce opportunities for harm if not done appropriately. This commentary presents a protocol to enhance the safety of deprescribing by considering the medication therapy needs of each individual patient.
Pronovost P, Armstrong M, Demski R, et al. Acad Med. 2015;90:165-172.
This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the Armstrong Institute for Patient Safety and Quality. The institute is led by safety expert Dr. Peter Pronovost and currently has approximately 70 staff members, 140 core faculty, and an annual budget of about $15 million. The new governance structure includes oversight from a patient safety and quality board committee. The overall goal of these efforts was to achieve quality metrics that would meet the requirements for the Delmarva Foundation Excellence awards and The Joint Commission's Top Performer award at each of the 5 Johns Hopkins hospitals (2 academic and 3 community institutions). By 2013, the health system reached at least 96% compliance on 6 of 7 targeted measures, with 4 hospitals receiving the Delmarva Foundation award and 2 hospitals garnering the Joint Commission award, making a strong case for the effectiveness of this robust high-reliability strategy.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
Hum Factors. 2006;48(1):1-108.
This set of ten articles addresses the role that human factors plays in patient safety issues, including medication administration barcoding, virtual reality simulation, and decision support system acceptance.
Lau DT, Kasper JD, Potter DEB, et al. Arch Intern Med. 2005;165:68-74.
Using a designated criteria system for inappropriate medication prescribing, this study examined the impact of such prescriptions on hospitalization and death. Studying more than 3300 nursing home residents, investigators reported greater odds of being hospitalized in the month following an inappropriate prescription, an associated greater risk of death, and similar risk with even intermittent exposure to such prescriptions. The authors conclude that their reported associations call for improved attention and education for providers who prescribe medications to the elderly.