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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 - 19 of 19 Results
Thompson KM, Swanson KM, Cox DL, et al. Mayo Clin Proc Innov Qual Outcomes. 2018;2:342-351.
This pre–post study found that medication administration errors decreased after the introduction of barcode medication administration, echoing prior studies. The authors conclude that use of barcode medication administration technology improves patient safety by reducing medication errors.
Wingo MT, Halvorsen AJ, Beckman T, et al. J Hosp Med. 2016;11:169-73.
The volume–outcome relationship—in which increased patient volume is associated with improved outcomes at the individual clinician and hospital level—has been demonstrated in several classic studies of surgical outcomes. However, this analysis of medical admissions to a teaching hospital found indications of an opposite association. Analyzing admissions over a 6-year period, investigators found that a higher total patient census and a greater number of daily admissions were both associated with an increased frequency of safety events (as measured by the AHRQ Patient Safety Indicators). Greater total census and more admissions were both inversely associated with teaching evaluation scores. Taken together, these results imply that increased workload impairs faculty physicians' ability to supervise and teach residents effectively.
Barwise A, Thongprayoon C, Gajic O, et al. Crit Care Med. 2016;44:54-63.
Despite widespread implementation of rapid response systems, they remain controversial. This study showed that delayed activation of rapid response was associated with worse morbidity and higher mortality compared to timely rapid response implementation. This work adds to recent data suggesting that rapid response improves patient safety.
Etzioni DA, Wasif N, Dueck AC, et al. JAMA. 2015;313:505-11.
Similar to another study published in the same issue of the Journal of the American Medical Association, this retrospective study found no association between participation in the National Surgical Quality Improvement Program and surgical outcomes over time. This study examined 3 and a half years of data from the University HealthSystem Consortium, which represents a large cohort of academic medical centers.
Moriarty JP, Schiebel NE, Johnson MG, et al. Int J Qual Health Care. 2014;26:49-57.
Although effectiveness of rapid response teams has traditionally been measured by using rates of cardiac arrests or intensive care unit transfers, this study advocates for using the AHRQ failure to rescue metric instead. Failure to rescue rates declined in the second year after implementation of the rapid response team in concert with increased utilization of the team.
Huddleston JM, Diedrich DA, Kinsey GC, et al. J Patient Saf. 2014;10:6-12.
This commentary describes how design and implementation of an institutional mortality review system evolved over 10 years. The reporting program offers insights about how to promote and enhance organizational learning.
Naessens JM, Campbell CR, Shah ND, et al. Am J Med Qual. 2012;27:48-57.
The epidemiology of adverse events on a population basis has been well studied, but how these data translate to risks for individual patients is not as clear. The likelihood of suffering an adverse event is directly tied to length of hospitalization, and this study sought to evaluate a complementary question: whether patients who are more severely ill at admission are at increased risk of preventable harm. By linking adverse event data from various sources—including Patient Safety Indicators, voluntary error reports, and infection control reports—to clinical databases, the authors were able to show that higher illness severity is associated with an increased risk of adverse events during hospitalization. These findings are supported by the fact that intensive care unit patients have consistently been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring in an acutely ill patient with multiple underlying comorbidities.
Cima RR, Lackore KA, Nehring SA, et al. Surgery. 2011;150:943-9.
This study found that the Patient Safety Indicators lacked sensitivity and specificity for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program adverse event detection methodology.
Grafft CA, McDonald FS, Ruud KL, et al. Arch Intern Med. 2010;170:955-60.
Hospital readmissions due to adverse events after discharge are relatively common, and may be precipitated by medication errors and failure to follow up on pending test results—problems that could, in theory, be averted by early outpatient follow-up. However, this Mayo Clinic study found that patients who were given follow-up appointments (at a mean of 6 days after discharge) were just as likely to be readmitted or visit the emergency room within 30 days after discharge as those without follow-up. Interventions such as those in the Care Transitions study and the Project RED study have relied on more comprehensive, nurse-driven interventions to reduce readmission rates and post-discharge emergency department visits.
Perspective on Safety October 1, 2008
Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.
Nassaralla CL, Naessens JM, Chaudhry R, et al. Qual Saf Health Care. 2007;16:90-4.
This prospective study found improvement in medication documentation at one clinic after implementing an intervention to improve the accuracy and completeness of the electronic medical record. The authors conclude that staff and patients need to actively participate in this process.