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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 - 7 of 7 Results
Hashmi ZG, Haut ER, Efron DT, et al. JAMA Surg. 2018;153:686-689.
Determining which harms are truly preventable remains an ongoing challenge in the field of patient safety. In a 2016 report, the National Academies of Sciences, Engineering, and Medicine called for achieving zero preventable trauma deaths, but the actual number of preventable trauma deaths in the United States remains unknown. Analyzing administrative data from more than 18 million patients across 2198 hospitals, investigators determined that if low-performing hospitals could provide the same quality of trauma care as high-performing centers, 100,000 lives could be saved over a 5-year period.
Sacks GD, Shannon EM, Dawes AJ, et al. BMJ Qual Saf. 2015;24:458-67.
Previous literature has shown that safety culture and nontechnical skills (such as communication) can affect safety and clinical outcomes in patients undergoing surgery. This systematic review identified several interventions that demonstrated effectiveness at improving various aspects of surgical culture, including teamwork and communication. A past AHRQ WebM&M commentary discussed disruptive behavior as a contributor to safety issues in surgery.
Sacks GD, Diggs BS, Hadjizacharia P, et al. Am J Surg. 2014;207:817-23.
The introduction of the Institute for Healthcare Improvement central line bundle into a surgical intensive care unit dramatically reduced the incidence of central line–associated bloodstream infections, preventing an estimated 2.5 deaths per year in this single unit.
DuBose JJ, Inaba K, Shiflett A, et al. J Trauma. 2008;64:22-27; discussion 27-29.
Clinicians constantly encounter the challenge of how to ensure that appropriate patient safety measures are reliably carried out, especially in complex environments such as the intensive care unit (ICU). Preventable complications have been successfully reduced through the use of checklists, analogous to those used in aviation. This study used a "quality rounds checklist," which was completed by the ICU fellow, to ensure that trauma ICU patients received important patient safety interventions (including some recommendations of the 100,000 Lives campaign). Use of the tool resulted in significant reductions in ventilator-associated pneumonia and central line–associated bloodstream infections. A prior study implemented a similar tool to ensure multidisciplinary communication in the ICU.