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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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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.
Fairbanks RJ, Wears RL, Woods DD, et al. Jt Comm J Qual Patient Saf. 2014;40:376-383.
Resilience is a characteristic that enables individuals to adapt to uncertain conditions in their work environment to prevent failure. Summarizing a workshop on how resilience can enhance patient safety, this commentary defines key elements of resilient organizations and provides examples of resilience engineering techniques applied in health care.
Lee GM, Kleinman K, Soumerai SB, et al. N Engl J Med. 2012;367:1428-37.
In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.
Sinkowitz-Cochran R, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-43.
The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.
Huskins C, Huckabee CM, O'Grady NP, et al. N Engl J Med. 2011;364:1407-18.
Antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecalis (VRE), are frequent sources of hospital-acquired infection (HAI) in the intensive care unit (ICU). Although the incidence of serious infections caused by MRSA has been decreasing, the optimal strategies to prevent spread of these bacteria remain unclear. In this cluster-randomized trial conducted in 18 ICUs, a protocol that involved universal surveillance and barrier precautions (gowns and gloves) for patients colonized with these bacteria was evaluated for effectiveness at preventing colonization and infection with MRSA or VRE. No reduction in colonization or infection was found, in part attributable to the fact that use of barrier precautions was suboptimal. Prior successful efforts to reduce HAI have emphasized the role of safety culture in addition to specific preventive interventions, an approach discussed in-depth in this analysis of the landmark Keystone ICU project.
Landrigan CP, Parry G, Bones CB, et al. N Engl J Med. 2010;363:2124-34.
… medical records from 10 North Carolina hospitals over a 6-year period, using the Institute for Healthcare … remained unchanged. Recent research has also confirmed a persistently high rate of adverse events in Medicare and … of the state of the field, including a commentary by Dr. Robert Wachter and a plenary session at the National Patient …
Kaushal R, Bates DW, Abramson EL, et al. Am J Health-Syst Pharm. 2008;65:1254-1260.
Medication errors are common in pediatric inpatients, but the best method of addressing them remains unclear. Studies of technological interventions, such as computerized provider order entry, have yielded inconsistent results. In this controlled trial, clinical pharmacists were deployed in the intensive care unit (ICU) and general medical and surgical wards in a pediatric hospital, and their effect on prevention of medication errors was assessed. Serious medication errors (including near misses) were significantly reduced in the ICU. No effect was seen on medication error rates for general ward patients, although the baseline rate of errors was much lower in those areas. A prior review documented the effectiveness of pharmacists at preventing medication errors in a variety of inpatient settings.
Sharek PJ, Horbar JD, Mason W, et al. Pediatrics. 2006;118:1332-40.
… events (AEs), have been used to screen for errors in a variety of clinical settings . This AHRQ–funded study used methodology similar to a prior study in adult intensive care unit patients to develop a chart-based set of triggers for error identification in the …