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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 - 10 of 10 Results
Bloo G, Calsbeek H, Westert GP, et al. J Patient Saf Risk Manag. 2023;28:31-46.
Racial and ethnic minoritized patients frequently have poorer postoperative outcomes. The hospital in this study found the opposite and sought the perspectives of minority and non-minority patients to explore potential contributing factors. Both groups of patients described positive communication with nurses and physicians, trust in the team, and family support. Only one unique factor came up for the ethnic minority patients: having someone, an interpreter, accompany them to the operating room made them feel safe.
Emond YEJJM, Calsbeek H, Peters YAS, et al. Br J Anaesth. 2022;128:562-573.
A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.
van Gelderen SC, Zegers M, Robben PB, et al. BMC Health Serv Res. 2018;18:798.
Auditing for compliance with safety practices is performed frequently in the health care setting, both for learning and feedback as well as for regulatory purposes. In this survey study involving boards of directors and hospital leaders from 89 acute care hospitals in the Netherlands, researchers sought to identify factors for effective auditing and provide suggestions for how hospital boards can use such auditing practices to inform governance.
van Dusseldorp L, de Waal GH-, Hamers H, et al. Jt Comm J Qual Patient Saf. 2016;42:545-554, AP1-AP3.
In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.
van Sluisveld N, Hesselink G, van der Hoeven JG, et al. Intensive Care Med. 2015;41:589-604.
This systematic review revealed that limited evidence exists exploring handoffs from intensive care units to general wards, and most of the studies identified were of low quality. Two promising interventions include employing liaison nurses working across multiple settings and structured communication, which has been shown to improve handoffs. The authors advocate for these interventions to be tested widely in rigorous studies to determine their effectiveness.
Heideveld-Chevalking AJ, Calsbeek H, Damen J, et al. Patient Saf Surg. 2014;8:46.
This study analyzed voluntarily reported safety incidents in the perioperative setting at a Dutch university hospital. Over 3 years, a total of 2563 incidents were reported—roughly half were adverse events and half were near misses. Similar to other studies, the majority of reporters were nurses.
Weenink JW, Westert GP, Schoonhoven L, et al. BMJ Qual Saf. 2015;24:56-64.
In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.
Borghans I, Hekkert KD, Ouden L den, et al. BMJ Open. 2014;4:e004773.
Currently, no reliable method exists for comparing patient safety between hospitals. The hospital standardized mortality ratio, which compares observed with expected mortality for specific diagnoses, is widely used but has been decried as inaccurate and subject to gaming. Similarly, deaths in patients with low-mortality diagnoses are also used to identify safety problems, but these events are rare and unpredictable in many cases. Adverse events are known to result in longer hospitalizations. This Dutch study used a national database to examine whether unexpectedly long length of stay could be used as an indicator of the safety and quality of care. This preliminary study found that rates of unexpectedly long hospital stays varied widely between hospitals and were correlated with other quality measures. Although much more work is required to validate this measure, it may fill a need as a measure of patient safety that allows comparisons between hospitals.
Hesselink G, Schoonhoven L, Barach P, et al. Ann Intern Med. 2013;157:417.
Care transitions remain a particularly vulnerable time for patient safety, leading to an increasing emphasis on effective handoff communication. Adverse events following hospital discharge are common, affecting nearly 20% of patients. This review summarizes interventions aimed at improving patient discharge from hospital to primary care; a number of effective strategies and measured outcomes are compiled. The efforts described are primarily focused on smoothing the coordination of care and communication between hospital and primary care providers and pharmacists. An AHRQ WebM&M conversation with Dr. Vineet Arora explores extra-hospital and intra-hospital handoffs.