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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 - 18 of 18 Results
Eggenschwiler LC, Rutjes AWS, Musy SN, et al. PLoS ONE. 2022;17:e0273800.
Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
Longhini J, Papastavrou E, Efstathiou G, et al. J Nurs Manag. 2021;29:572-583.
… system level, indicating missed nursing care is not merely a nursing issue. Nurse managers play a key role in implementing strategies at the nursing and … care: an international qualitative study based upon a positive deviance approach. J Nurs Manag. …
Ausserhofer D, Zaboli A, Pfeifer N, et al. Int J Nurs Stud. 2020;113:103788.
… result in delays in care and adverse events . Conducted at a single emergency department (ED) in Italy, this study found … with longer emergency department and hospital stays. … Ausserhofer D, Zaboli A, Pfeifer N, et al. Errors in nurse-led triage: an …
Aiken LH, Sloane DM, Griffiths P, et al. BMJ Qual Saf. 2017;26:559-568.
Researchers analyzed patient discharge data and hospital characteristics, as well as patient and nurse survey data, across adult acute care hospitals in six European countries. After adjusting for hospital and patient variables, they found that hospitals in which nursing care was provided to a greater degree by skilled nurses had lower odds of mortality. The authors argue against replacing professional nurses with nursing assistants and suggest that doing so may compromise patient safety by increasing preventable deaths.
Pedroja AT, Blegen MA, Abravanel R, et al. J Patient Saf. 2014;10:168-75.
… events . This observational study sought to develop a metric of hospital system load—a multidimensional measure of overall hospital workload—and … to validate the system load metric, this study provides a new method to quantify system stressors that could affect …
Ausserhofer D, Zander B, Busse R, et al. BMJ Qual Saf. 2014;23:126-35.
Nurses are frequently forced to prioritize tasks during busy shifts, leading to some nursing care being left undone. In this multinational European study, nurses most frequently omitted time-intensive but critical practices such as talking with, educating, and providing comfort for patients.
Sehgal NL, Green A, Vidyarthi A, et al. J Hosp Med. 2010;5:234-9.
This study discovered that while nurses and physicians use patient whiteboards differently, they all value its potential for improving teamwork, communication, and patient care. The authors provide a series of recommendations for those adopting whiteboards and advocate for their use as a patient-centered tool.
Kliger J, Blegen MA, Gootee D, et al. Jt Comm J Qual Patient Saf. 2009;35:604-12.
… quality and patient safety … Jt Comm J Qual Patient Saf … A significant proportion of medication errors occur at the … To address this problem, seven hospitals participated in a quality improvement collaborative to engage frontline … in addressing medication administration errors. Through a rapid-cycle improvement process , each hospital developed …
WebM&M Case May 1, 2006
… The Case … An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered from … even when these practices are not the most efficient. … Mary A. Blegen, RN, PhD … Professor in Community Health System …
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2011;21.
Focused efforts to enhance teamwork and communication have led to improved safety culture, though the impact on clinical outcomes is mixed. This multicenter study evaluated the impact of a series of teamwork and communication interventions over a 2-year period. The interventions included a teamwork training program, the development of unit-based safety teams, and patient engagement through daily goals and whiteboard use. Although a related study demonstrated that the interventions led to improved safety culture, this study found no impact on readmission rates or length of stay. Interviewing patients both during and after hospitalization, investigators found that patients perceived greater team function, but that they also perceived more safety gaps. This raises the possibility that patients' heightened awareness regarding patient safety and teamwork may lead them to identify more flaws in the system.