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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 101 Results
Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.
Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.
Paine LA, Holzmueller CG, Elliott R, et al. J Healthc Risk Manag. 2018;38:36-46.
… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership …
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
… decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care … detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication …
Rawat N, Yang T, Ali KJ, et al. Crit Care Med. 2017;45:1208-1215.
… infections . This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients … in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the …
Makary MA, Daniel M. BMJ. 2016;353:i2139.
… yearly. More recent studies have challenged that estimate. A recent British study found that only 3.6% of inpatient … too many patients die needlessly due to unsafe care. … Makary MA, Daniel M. Medical error-the third leading cause of death in the US.  …
Pronovost P, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.
This study updates the previously described progress of patient safety efforts at Johns Hopkins Hospital. In 2012, hospital leaders declared their goal of exceeding The Joint Commission Top Performer award thresholds by achieving at least 96% compliance on accountability measures. The program included creating a robust quality management infrastructure through the Armstrong Institute, engaging frontline clinicians in peer learning communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving metrics. This study describes how the hospital was able to sustain performance on all of the accountability measures through 2014. The authors attribute their continued success to establishing an enduring quality management infrastructure, a project management office, and a formal accountability framework. This model highlights the degree of organization required to create lasting changes that improve patient safety across health systems.
Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.
Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.
Rosen MA, Goeschel CA, Che X-X, et al. Simul Healthc. 2015;10:372-377.
… widely diverging participant responses. There was a lack of leadership engagement with frontline staff around … in their safety strategies. Simulation appears to be a promising leadership education strategy that may uncover gaps in current leadership practices. A PSNet perspective explored how leaders can promote cultural …
Xu T, Wick EC, Makary MA. BMJ Qual Saf. 2016;25:311-314.
This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.
Pronovost P, Armstrong M, Demski R, et al. Acad Med. 2015;90:165-172.
… … Acad Med … This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the … The new governance structure includes oversight from a patient safety and quality board committee. The overall …
Lyu HG, Cooper M, Mayer-Blackwell B, et al. J Patient Saf. 2017;13:199-201.
… Journal of patient safety … J Patient Saf … Patient stories are a growing component of understanding the impact of medical … echo prior literature on patient reports. A past AHRQ WebM&M perspective explores best practices for error disclosure. …
Bixenstine PJ, Shore AD, Mehtsun WT, et al. J Healthc Qual. 2013;36:43-53.
J Healthc Qual … Proposals to reform the medical malpractice … Catastrophic payments most frequently arose as a result of a diagnostic error and were more likely to occur for … was discussed by Dr. Troyen Brennan in a past AHRQ WebM&M interview . …

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 … … Nancy … Eve … Jennifer … Kelly … Margaret … Tom … Robert … Lisa … Robert … Valerie … Neil … Donald … John … … … Jernigan … Perl … Septimus … Maragakis. … Coffin … S … JM … P … R … N … P … S … A … L … AM … O … AAMJ
Goutier JM, Holzmueller CG, Edwards KC, et al. Infect Control Hosp Epidemiol. 2014;35:998-1005.
Ventilator-associated pneumonia is one of the most common health care–associated infections in intensive care unit patients. This systematic review identifies several strategies, including standardization of care processes, performing regular data audits, and providing feedback, that can enhance adoption of evidence-based preventive strategies.
Thompson DA, Marsteller JA, Pronovost P, et al. J Patient Saf. 2015;11:143-51.
… Journal of patient safety … J Patient Saf … This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery …