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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 - 20 of 27 Results
Ly DP, Shekelle PG, Song Z. JAMA Intern Med. 2023;183:818-823.
Anchoring bias is the tendency to focus on an initial diagnosis despite later evidence to the contrary. This study measured physicians’ potential anchoring bias regarding patients with congestive heart failure (CHF) with shortness of breath presenting to the emergency department. When the patient’s initial triage note included CHF, physicians were less likely and/or slower to test for pulmonary embolism (PE) than when the triage note did not mention CHF. This suggests physicians may have been subject to anchoring bias.
Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
McCleskey SG, Shek L, Grein J, et al. BMJ Qual Saf. 2022;31:308-321.
Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.
… JAMA Netw Open … Fall prevention in healthcare settings is a patient safety priority . This systematic review found that … on fall prevention and management for older adults: a systematic review. JAMA Netw Open. 2021;4(12):e2138911. …
Bhasin S, Gill TM, Reuben DB, et al. N Engl J Med. 2020;383:129-140.
… ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury , … trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care. … Bhasin S, Gill TM, Reuben DB, et al. A randomized trial of a multifactorial strategy to prevent …
Greeley AM, Tanner EP, Mak S, et al. Ann Intern Med. 2020;172:317-324.
… hospitals and only moderate-certainty that alternatives (e.g., video monitoring) can reduce sitter use without … as useful as initially believed. All included studies had a least one methodological limitation (such as not defining what consisted a fall, lack of outcome assessor blinding). … Greeley AM, …
Sarkar U, McDonald KM, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.
Patient safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the methods and results of an AHRQ Technical Brief, this commentary summarizes expert opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors outline patient safety practices relevant to the ambulatory setting and suggest activities to advance improvement efforts in outpatient care, such as measure development and use of health information technologies.
Ahluwalia SC, Damberg CL, Silverman M, et al. Jt Comm J Qual Patient Saf. 2017;43:450-459.
This systematic review sought to identify a consistently used definition of a high-performing health system. Less than 20% of the included studies defined patient safety as an aspect of high performance. In a related editorial, Dr. Peter Pronovost asserts that inconsistency in defining high performance reflects the need to focus on the purpose of health care in order to achieve transformative improvement.
Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.
Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015;150:796-805.
This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.
Shekelle PG, Pronovost P, Wachter R, et al. Ann Intern Med. 2013;158:365-8.
… in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor … The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, … reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal …
Taylor SL, Dy SM, Foy R, et al. BMJ Qual Saf. 2011;20:611-7.
Based on discussions from a 22-person expert panel, this study described four contextual domains judged as important for patient safety practices. The domains included: safety culture, teamwork, and leadership involvement; structural organizational characteristics; external factors (e.g., incentive systems); and availability of implementation and management tools.
Shekelle PG, Pronovost P, Wachter R, et al. Ann Intern Med. 2011;154:693-6.
Research on patient safety has dramatically increased in the past decade, but despite this, the progress of improving safety remains slow. Significant controversy exists about how safety interventions should be evaluated, and even apparently successful interventions may not be generalizable to all settings. This AHRQ-sponsored consensus statement by leaders in the safety field defines a framework for rigorous assessment of safety interventions. This framework calls for investigators to use change theory to develop their projects; provide adequate details of the intervention, implementation process, and the context in which the intervention was conducted; and evaluate both the expected outcomes and potential unintended consequences of the intervention. The accompanying editorial (see link below) discusses the challenges of conducting research in complex settings, and takes note of existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.
Ovretveit JC, Shekelle PG, Dy SM, et al. BMJ Qual Saf. 2011;20:604-10.
The context in which a patient safety intervention is implemented can be as important for success as the strength of the intervention itself. However, this review of five widely accepted patient safety practices found that few specifically evaluated contextual factors during implementation.
Foy R, Hempel S, Rubenstein L, et al. Ann Intern Med. 2010;152:247-58.
This meta-analysis found that interactive communication between collaborating primary care providers and specialists (psychiatrists and endocrinologists in this study) is associated with improved patient outcomes. The interactive communication methods included joint consultations, scheduled phone discussions, and shared documentation, with the authors suggesting a need for changes in reimbursement models to support such interventions.