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.
Kennerly DA, Kudyakov R, da Graca B, et al. Health Serv Res. 2014;49:1407-1425.
Using the Institute for Healthcare Improvement's Global Trigger Tool, this retrospective study analyzed adverse events at a large health care system in Texas. Approximately one-third of patients experienced at least one adverse event during their hospital stay. The vast majority of these incidents were deemed potentially preventable. Surgical and procedural complications accounted for a large portion of adverse events in the hospital. Less than 5% of the hospital-acquired adverse events identified in this study would have been discovered through voluntary reporting or use of AHRQ Patient Safety Indicators, illustrating the challenges of detecting safety hazards. A previous AHRQ PSNet interview with Dr. David Classen explored the use of trigger tools to measure patient safety.
Kennerly DA, Saldaña M, Kudyakov R, et al. J Patient Saf. 2013;9:87-95.
… for Healthcare Improvement's Global Trigger Tool is a widely used approach for detecting and monitoring safety … of the Global Trigger Tool, with the goal of developing a sustainable mechanism for identifying adverse events (AEs), …
Compton J, Copeland K, Flanders S, et al. Jt Comm J Qual Patient Saf. 2012;38:261-8.
In this study, implementation of system-wide training and adoption of the structured communication tool SBAR were associated with challenges in uptake and physician education. However, in situations where SBAR was used correctly, physicians were more likely to be able to make clinical decisions.