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.
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Guo W, Li Y, Temkin-Greener H. J Am Med Dir Assoc. 2021;22:2384-2388.e1.
This study examined the association between patient safety culture (PSC) measured by the Nursing Home Survey on Patient Safety Culture and community discharge of long-term care (LTC) residents. Results show that two domains of PSC- teamwork and supervisor expectations and actions regarding patient safety- are significantly associated with increased likelihood of discharge to a community setting. Focusing on these domains to improve patient safety culture may also increase community discharge rates.
Sloane PD, Yearby R, Konetzka RT, et al. J Am Med Dir Assoc. 2021;22:886-892.
Racial bias and racism are increasingly seen as a critical patient safety issue. In this article, the authors outline the components of systemic racism (structural/institutional, cultural, and interpersonal), how they manifest and affect the long-term care system, and the detrimental impact of systemic racism on Blacks during the COVID-19 pandemic.
Orth J, Li Y, Simning A, et al. Gerontologist. 2021;61:1296-1306.
Nursing home patient safety culture is associated with healthcare quality and patient outcomes. This large cross-sectional study of nursing homes in the United States found that speaking-up behavior and communication openness were associated with a decreased risk of in-residence death among older adults with dementia. This association was strong in nursing homes located in states with higher nursing home nurse staffing requirements.
Zimmerman S, Sloane PD, Katz PR, et al. J Am Med Dir Assoc. 2020;21.
Older adults are particularly vulnerable to COVID-19. This editorial discusses the unique challenges faced by assisted living communities and implications for care, such as the prevalence of dementia and limited medical and nursing provider presence, as well as action steps communities should consider during planning around and responding to the COVID-19 pandemic.
Li Y, Cen X, Cai X, et al. Med Care. 2019;57:641-647.
This cross-sectional study found that nursing homes with higher scores on Nursing Home Survey on Patient Safety Culture performed better in measures of quality and safety. A prior PSNet perspective discussed how to change a safety culture.
Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Med Care. 2017;55:447-455.
The Centers for Medicare and Medicaid Services policy on nonpayment for certain hospital-acquired conditions serves as a strong incentive to prevent adverse events during hospitalization. This observational study examined Medicare's nonpayment policy for conditions such as health care–associated infections. As with prior studies, investigators determined that the incidence of hospital-acquired conditions declined following implementation of nonpayment. For certain conditions, such as catheter-associated urinary tract infections, hospitals with a larger proportion of Medicare patients had greater improvements. The authors note the variation in rates of hospital-acquired conditions and differing magnitude of improvement. They recommend further study to understand how to achieve similar successes in reducing hospital-acquired conditions.
Crane S, Sloane PD, Elder NC, et al. J Am Board Fam Med. 2015;28:452-60.
This study describes the successful implementation of a Web-based reporting system for near-miss events in primary care practices. The most prevalent reports were breakdowns in office processes, with varying risk for adverse events, as found in prior studies of incident reporting. Although near-miss reporting can stimulate improvement efforts, it is not a precise method for detecting safety problems.
Zimmerman S, Love K, Sloane PD, et al. J Am Geriatr Soc. 2011;59:1060-8.
Medication errors are common in long-term care facilities, and prior research has shown that many of these errors occur at medication administration. This is particularly a problem at assisted living facilities where non-nursing clinical staff (such as medication aides) are often charged with administering medications. Direct observation of medication administration at two assisted living facilities in this study found that the overall error rate was similar between nurses and non-nurses, but less trained staff from either discipline had markedly higher error rates. As the regulations regarding medication administration in assisted living facilities vary from state to state, the authors advocate for more uniform training standards for all staff authorized to administer medications.