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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 - 9 of 9 Results
Tedesco D, Moghavem N, Weng Y, et al. J Patient Saf. 2021;17:e327-e334.
Using nationally representative, all-payer discharge data, these authors examined temporal changes in AHRQ’s patient safety indicators (PSIs) and their association with national pay-for-performance reforms. From 2000 – 2013, the researchers found decreased rates for ten of thirteen PSIs and an increase in the rate of three PSIs (iatrogenic pneumothorax, postoperative sepsis, and postoperative physiologic or metabolic derangement). The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates.
Tedesco D, Asch SM, Curtin C, et al. Health Aff (Millwood). 2017;36:1748-1753.
Using data from the Healthcare Cost and Utilization Project, this retrospective secondary data analysis found an overall increase in opioid-related hospital visits, with a peak in 2010 and gradual decline since then. Coincident with the decline in opioid-related visits, a sharp rise in heroin-related hospital visits emerged. These results underscore the concern that tighter controls on opioid medications may lead to heroin use.
Moghavem N, McDonald KM, Ratliff JK, et al. Med Care. 2016;54:359-64.
The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. This study demonstrated that PSIs were associated with longer hospital stays and increased mortality. Neurosurgery patients were more likely to have PSIs occur than other surgical patients.
Braddock CH, Szaflarski N, Forsey L, et al. J Gen Intern Med. 2015;30:425-33.
This before-and-after study examined the impact of a patient safety project which included simulation training, teamwork training, and patient safety educational conferences. The authors found a decrease in hospital-acquired complications, better nurse perceptions of safety culture, and an improved observed-to-expected mortality ratio. These promising preliminary results should spur larger studies of these organizational safety efforts.
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Ann Plast Surg. 2015;74:597-602.
Using AHRQ patient safety indicators, this study established that approximately 4% of plastic surgery patients experience an adverse event during their hospital stay. This rate is relatively low compared with other surgical disciplines, but it is significant due to the proportion of young healthy patients who undergo plastic surgery.
Hernandez-Boussard T, McDonald KM, Morton J, et al. J Am Coll Surg. 2012;214:788-97.
Vascular surgery is considered a higher risk surgical specialty, as many patients undergoing vascular procedures are elderly and have other comorbid illnesses, putting them at elevated risk of postoperative complications. This study used Patient Safety Indicators (PSIs) to analyze more than 1.4 million patients who underwent vascular surgery from 2005–2009 and found that more than 5% experienced a postoperative adverse event. Procedural complexity and comorbidities were associated with increased risk of a PSI, corroborating prior studies that have found a link between illness severity and risk of complications in medical patients. The PSIs are best used to screen administrative data for potential adverse events, as in this study. In surgical patients, the National Surgical Quality Improvement Program measures have been shown to be superior for accurate detection of postoperative adverse events.
Hernandez-Boussard T, Downey JR, McDonald KM, et al. Health Serv Res. 2011;47.
Studying the relationship between hospital volume, surgical volume, and clinical outcomes, past research in part led to recommendations for volume-based referral as a safety practice. However, the volume–outcome relationship may be limited to selected surgical procedures, suggesting that systematic volume-based referral is unnecessary. This study further examines these relationships by evaluating the impact of hospital surgical volume on preventable adverse events. The latter were measured using the AHRQ Patient Safety Indicators (PSIs), which have noted limitations as measures of safety. Nevertheless, investigators found that hospital volume for abdominal aortic aneurysm, coronary bypass graft, and Roux-en-Y gastric bypass were inversely related to PSI rates. Additional research to further evaluate the structural and process differences between outcomes and hospital volume may help identify potential safety solutions.
Downey JR, Hernandez-Boussard T, Banka G, et al. Health Serv Res. 2012;47:414-30.
As the patient safety movement enters its second decade, an emerging body of research is finding that safety for hospitalized patients has likely not improved significantly over the past several years. This study, which used the AHRQ Patient Safety Indicators (PSIs) to analyze safety events in 69 million hospitalizations over a 10-year period, also finds no clear evidence of improved safety. Of the 20 PSIs analyzed, 7 increased in incidence over the time period studied, 7 decreased, and 6 did not change. While PSIs are best used for screening purposes and not for direct comparisons between hospitals, they have been used to track system-level rates of safety problems over time. The results of this study and other recent literature provide continued urgency for the safety movement to strive to improve the safety of the entire health care system.