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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 - 12 of 12 Results
Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Koers L, van Haperen M, Meijer CGF, et al. JAMA Surg. 2019;155:e194704.
… and failure to adhere to best practices.   … Koers L, van Haperen M, Meijer CGF, van Wandelen SBE, Waller E, Dongelmans D, Boermeester MA, Hermanides J, Preckel B.  Effect of cognitive aids on adherence to best …
de Vries EN, Prins HA, Bennink C, et al. BMJ Qual Saf. 2012;21:503-8.
Checklists have been integral components in some of the most notable successes of the patient safety movement. However, the mechanism by which checklists improve outcomes is not entirely clear. A previously published surgical safety system, centered around detailed checklists for the entire preoperative, operative, and postoperative phases, achieved remarkable improvement in surgical outcomes. This study analyzed the checklists themselves to attempt to discern how they improved safety. At least one potential safety incident was intercepted in almost 40% of patients undergoing surgery. The majority of these were detected postoperatively—even though checklist adherence was lowest in the postoperative period. As prior studies have shown that postoperative care quality likely contributes to hospital-level variations in surgical mortality, this checklist's most important effect likely involved facilitating early detection of postoperative adverse events.
de Vries EN, Prins HA, Crolla RMPH, et al. N Engl J Med. 2010;363:1928-37.
A landmark study in patient safety demonstrated remarkable improvement in surgical outcomes through implementation of a checklist for intraoperative and perioperative care. However, inconsistencies in postoperative care are thought to contribute to persistent variation in surgical outcomes between hospitals. In this controlled study, a comprehensive system for the entire surgical pathway—from admission to discharge—was implemented at six teaching hospitals in the Netherlands, and resulted in significant reductions in both complications and overall mortality. The authors note that the success of their intervention relied as much on developing a culture of safety as on the checklist itself, a point supported by another recent study that achieved significant improvement in surgical outcomes through teamwork training.