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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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Approach to Improving Safety
Displaying 1 - 20 of 67 Results
Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.
Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.
Wick EC, Sehgal NL. JAMA Surg. 2018;153:948-954.
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Lin DM, Carson KA, Lubomski LH, et al. J Am Coll Surg. 2018;227:189-197.e1.
This pre–post study applied an evidence-based approach—the AHRQ Safety Program for Surgery—to colorectal cancer surgeries. The program was associated with a significant reduction in surgical site infections and an improvement in safety culture.
Ban KA, Gibbons MM, Ko CY, et al. Anesth Analg. 2019;128:879-889.
Standardization of care protocols has been shown to improve perioperative outcomes. This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring in implementing these recommendations.
Lyu H, Xu T, Brotman D, et al. PLoS One. 2017;12:e0181970.
Overuse of medical care can lead to patient harm. In this survey study, physicians were queried about the overuse of health care as well as contributing factors and solutions. Fear of malpractice was cited as a major reason for overtreatment.
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.
Rawat N, Yang T, Ali KJ, et al. Crit Care Med. 2017;45:1208-1215.
Patients requiring intensive care are particularly vulnerable to preventable adverse events, including health care–associated infections. This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients requiring mechanical ventilation in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the Comprehensive Unit-based Safety Program, focusing on implementing evidence-based safety processes by explicitly addressing barriers to improvement and engaging in regular data audit and feedback. Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events (including ventilator-associated pneumonia) over the study period. Although the study is limited by lack of a concurrent control group, the results indicate the power of collaborative efforts to drive large-scale improvement.
Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2017;92:608-613.
Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.
Pronovost P, Watson S, Goeschel CA, et al. Am J Med Qual. 2016;31:197-202.
A major challenge in improving patient safety is sustaining gains from new interventions over time. The landmark Michigan Keystone ICU project was a large-scale quality improvement effort that led to near elimination of central line–associated bloodstream infections (CLABSIs). This study examined practices to prevent CLABSIs in Michigan over the 10 years following that study. Investigators found a continued decline in CLABSIs from 2005 through 2013, with many participating hospitals reaching the benchmark rate of less than 1 CLABSI per 1000 hospital days after the initial project period ended. The authors credit robust training in change management principles and ongoing support for maintaining CLABSI prevention work. They further suggest that policymakers harness these methods to sustain patient safety efforts instead of relying on pay-for-performance incentives. A PSNet interview with the study's lead author explores, among other things, how to sustain changes in practice.
Makary MA, Daniel M. BMJ. 2016;353:i2139.
How many patients die each year due to preventable adverse events is difficult to determine. Early studies summarized in the seminal To Err Is Human report yielded an estimate of 44,000 to 98,000 deaths due to errors yearly. More recent studies have challenged that estimate. A recent British study found that only 3.6% of inpatient deaths were potentially avoidable, which translates to approximately 26,000 preventable deaths each year in the United States. This commentary argues that preventable deaths total more than 250,000 deaths per year, which would rank medical errors as the third most common cause of death. This estimation was developed by extrapolating preventable death rates from several studies with different methodologies to estimate avoidable adverse events; no formal meta-analysis was performed. It is important to note that discerning the preventability of adverse events (and consequent deaths) is difficult. Most studies of preventable harm find that even experienced clinical reviewers achieve only moderate interrater agreement on whether an adverse event occurred and, if so, whether it contributed to death. Although this article's estimate is likely to be controversial, the authors do highlight the lack of accurate strategies for measuring safety events—a problem also highlighted in a recent commentary by two patient safety leaders. Regardless of the exact number, too many patients die needlessly due to unsafe care.
Pronovost P, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.
This study updates the previously described progress of patient safety efforts at Johns Hopkins Hospital. In 2012, hospital leaders declared their goal of exceeding The Joint Commission Top Performer award thresholds by achieving at least 96% compliance on accountability measures. The program included creating a robust quality management infrastructure through the Armstrong Institute, engaging frontline clinicians in peer learning communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving metrics. This study describes how the hospital was able to sustain performance on all of the accountability measures through 2014. The authors attribute their continued success to establishing an enduring quality management infrastructure, a project management office, and a formal accountability framework. This model highlights the degree of organization required to create lasting changes that improve patient safety across health systems.
Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.
Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.
Xu T, Wick EC, Makary MA. BMJ Qual Saf. 2016;25:311-314.
This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.
Gould LJ, Wachter PA, Aboumatar HJ, et al. Jt Comm J Qual Patient Saf. 2015;41:387-395.
Forming clinical communities that commit to shared goals can augment quality improvement efforts. This commentary describes the development of 14 clinical communities as a way to support institutional quality improvement goals in a large health care system. The authors report the benefits of the program, which enhanced access to expertise and collective knowledge. The article highlights the use of a unit-level engagement model and physician champions as key elements for the success of clinical communities.
Pronovost P, Holzmueller CG, Molello NE, et al. Acad Med. 2015;90:1331-9.
Academic medical centers can serve as educational leaders in patient safety improvement. This commentary describes the development of the Armstrong Institute at Johns Hopkins which generated multidisciplinary educational programs and research opportunities that engaged clinicians, administrators, and patients in setting goals to improve safety at their institution. The authors provide insights regarding establishing a safety governance structure, setting a committee agenda, and implementing and evaluating interventions.
Pronovost P, Armstrong M, Demski R, et al. Acad Med. 2015;90:165-172.
This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the Armstrong Institute for Patient Safety and Quality. The institute is led by safety expert Dr. Peter Pronovost and currently has approximately 70 staff members, 140 core faculty, and an annual budget of about $15 million. The new governance structure includes oversight from a patient safety and quality board committee. The overall goal of these efforts was to achieve quality metrics that would meet the requirements for the Delmarva Foundation Excellence awards and The Joint Commission's Top Performer award at each of the 5 Johns Hopkins hospitals (2 academic and 3 community institutions). By 2013, the health system reached at least 96% compliance on 6 of 7 targeted measures, with 4 hospitals receiving the Delmarva Foundation award and 2 hospitals garnering the Joint Commission award, making a strong case for the effectiveness of this robust high-reliability strategy.
Lyu HG, Cooper M, Mayer-Blackwell B, et al. J Patient Saf. 2017;13:199-201.
Patient stories are a growing component of understanding the impact of medical errors on patients. This study analyzed voluntary survey data collected by an independent nonprofit news organization from patients regarding harm related to medical care. Almost half of respondents filed a complaint with an oversight agency, a much higher proportion than indicated in previous studies. Only 11.4% of patients reported receiving an apology, suggesting that disclosure and apology programs may remain incompletely implemented. About 20% filed a malpractice claim, consistent with prior data. Taken together, responses from this online public survey echo prior literature on patient reports. A past AHRQ WebM&M perspective explores best practices for error disclosure.
Bixenstine PJ, Shore AD, Mehtsun WT, et al. J Healthc Qual. 2013;36:43-53.
Proposals to reform the medical malpractice system often include caps on payouts, under the assumption that such large awards drive up overall health care costs. This analysis of data from the National Practitioner Data Bank examined the characteristics of catastrophic payouts, in which the plaintiff received $1 million or more. The investigators found that catastrophic payouts accounted for less than 8% of all paid malpractice claims, and they made up only 0.05% of total yearly health care expenditures. Catastrophic payments most frequently arose as a result of a diagnostic error and were more likely to occur for anesthesia and obstetric complications resulting in severe injury or death. The intersection between patient safety and the malpractice system was discussed by Dr. Troyen Brennan in a past AHRQ WebM&M interview.

Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801.

Preventing healthcare-acquired infections (HAIs) remains a patient safety priority. Based on a collaborative effort led by the Society for Healthcare Epidemiology in America (SHEA) and the Infectious Diseases Society of America (IDSA), this practice guideline builds on previous work and summarizes strategies to prevent common HAIs (i.e., catheter-associated urinary tract infections, Clostridium difficile infections, surgical site infections, central line-associated bloodstream infections, methicillin-resistant Staphylococcus aureus infections, and ventilator-associated pneumonia) as well as strategies to increase hand hygiene to prevent HAIs.