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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 - 11 of 11 Results
Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;17:e1285-e1295.
Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.
Sauro KM, Soo A, de Grood C, et al. Crit Care Med. 2020;48:946-953.
Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.
Sauro K, Ghali WA, Stelfox HT. BMJ Qual Saf. 2019;29:341-344.
This commentary discusses the challenges associated with detecting and measuring adverse events, the limitations of measurement alone, and the existing methodologies that can be leveraged to improve the accuracy of adverse event detection.
Stelfox HT, Soo A, Niven DJ, et al. JAMA Intern Med. 2018;178:1390-1399.
This retrospective observation cohort study conducted at nine hospitals sought to determine whether discharge from the intensive care unit (ICU) directly to home affected odds of readmission within 30 days or mortality within 1 year. Overall, patients discharged from the ICU to home are younger and less ill than patients who are transferred from the ICU to the hospital ward before returning home. The proportion of patients discharged from ICU to home varied widely by site. When researchers compared patients discharged from ICU to home to patients of similar age and severity of illness upon ICU admission who were discharged home from the hospital ward, they found no differences in odds of readmission or mortality. A related commentary explores why discharges from ICU to home occur and calls for implementing care transitions best practices upon ICU discharge in order to support optimal patient outcomes and prevent readmissions.
Boyd J, Wu G, Stelfox HT. J Hosp Med. 2017;12:675-682.
Checklists are a cornerstone of patient safety. This systematic review of randomized controlled trials of checklists in acute care settings demonstrated reduced mortality, decreased postoperative complications, and improved adherence to patient safety procedures. The authors call for additional, high-quality randomized studies of checklists.
Niven DJ, Bastos JF, Stelfox HT. Crit Care Med. 2014;42:179-87.
Formal transition programs for patients being discharged from the intensive care unit (ICU) to general wards, which generally involved proactive surveillance by a nurse or physician, were associated with a decreased risk of readmission to the ICU.
Li P, Ali S, Tang C, et al. J Hosp Med. 2013;8:456-63.
Clinical care handoffs occur multiple times every day for each hospitalized patient, and the use of information technology has been advocated as a means of standardizing and improving the quality of handoffs. Although this systematic review identified six controlled studies of computerized handoff tools, it found only limited evidence linking use of such a tool to improved patient outcomes. The available evidence (including a recently published study that was not included in this review) does indicate that computerized handoff tools improve the accuracy and completeness of physician tools, and may improve physician efficiency. A case of a preventable adverse event due to suboptimal handover is discussed in this AHRQ WebM&M commentary.
Li P, Stelfox HT, Ghali WA. Am J Med. 2011;124.
Physicians and patients generally expressed satisfaction with the handoff process when patients were transferred from the intensive care unit to the general ward. However, direct verbal communication occurred in only a small minority of cases, and several preventable errors did occur, implying the need for a more standardized process.
Montini T, Noble AA, Stelfox HT. Int J Qual Health Care. 2008;20:412-20.
This study developed a taxonomy for coding patient complaints to provide opportunities for quality improvement in patient care and satisfaction.
Stelfox HT, Bates DW, Redelmeier DA. JAMA. 2003;290:1899-1905.
This study discovered that patients isolated for colonization or infection with methicillin-resistant Staphylococcus aureus suffered more preventable adverse events, less satisfaction with care, and less documentation for their care, but no difference in mortality compared to a control group. Examples of the reported differences in care quality included absence of accurately recorded vital signs, missing daily physician progress notes, and less delivery of disease-specific standards for heart failure management. While safety precautions and isolation of selected patients certainly reduce the transmission of communicable infections, a potential patient safety issue results from the care these patients receive once isolated—an unintended adverse consequence.