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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 54 Results
Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. JAMA Pediatr. 2022;176:690-698.
Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.
Rosen MA, Mueller BU, Milstone AM, et al. Jt Comm J Qual Patient Saf. 2017;43:224-231.
This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.
Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2017;92:608-613.
Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.
Cifra CL, Bembea MM, Fackler JC, et al. Crit Care Med. 2016;17:58-66.
… to learn from medical errors. In this study, introducing a structured systems-oriented morbidity and mortality conference in a pediatric intensive care unit led to higher attendance … interventions. … Cifra CL, Bembea MM, Fackler JC, Miller MR. Transforming the Morbidity and Mortality …
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.
Rinke ML, Bundy DG, Abdullah F, et al. J Patient Saf. 2015;11:123-34.
Some states require public reporting of rates of central line–associated bloodstream infections (CLABSI). Investigators did not find differences in CLABSI rates between states with and without public reporting, suggesting that current transparency efforts are not sufficient to improve this safety target.
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 …
Cifra CL, Bembea MM, Fackler JC, et al. Crit Care Med. 2014;42:2252-7.
Similar to prior research in internal medicine and surgical programs, this survey study found that structure and processes of morbidity and mortality (M&M) conferences in pediatric intensive care units varied widely. Moreover, there was substantial disagreement between respondents, making it unclear whether the M&M conferences actually conform to key elements of medical incident analysis.
Pronovost P, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.
In 2010, The Joint Commission created accountability measures, evidence-based practices that produce positive impacts on patient outcomes. Each year, The Joint Commission recognizes Top Performers that provide more than 95% of their patients with recommended therapies for at least 3 accountability metrics. This article details Johns Hopkins Hospital's efforts to exceed the Top Performer award thresholds on multiple core measures. To realize this goal, the group developed a conceptual model that addresses the challenges accompanying quality and safety interventions. They also employed the Lean framework of define-measure-analyze-improve-control to help teams systematically create improvement plans. In addition, a monthly performance dashboard provided transparency and accountability. These efforts led to Johns Hopkins Hospital achieving a compliance goal of 96% or higher on 95% of the core measures in 2012. A previous AHRQ WebM&M interview with Dr. Peter Pronovost, the lead author of this paper, discussed the science of improving patient safety.
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 …
Pham JC, Andrawis M, Shore AD, et al. J Healthc Qual. 2011;33:9-18.
A convincing body of literature demonstrates that adequate nurse staffing improves patient safety. However, achieving an appropriate nurse-to-patient ratio may necessitate using temporary staff, who may themselves be a source of error due to being unfamiliar with the care environment. This analysis of national MEDMARX data found that medication errors committed by temporary staff, primarily nurses, were more likely to cause patient harm than errors committed by regular staff. Although the findings may represent reporting bias, since MEDMARX consists of voluntarily reported data, prior studies have also demonstrated that high levels of temporary staff may pose patient safety risks.
Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-92.
… The Journal of emergency medicine … J Emerg Med … A 2006 Institute of Medicine report highlighted growing … and its impact on safety. Medication errors are a known safety threat , and this study provides a cross-sectional perspective using reports from the MEDMARX …
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.
WebM&M Case March 1, 2011
Providers caring for an infant admitted with a viral infection and history of congenital heart disease failed to appreciate the significance of his low intake and output. The infant developed severe hypoglycemia and dehydration, and wound up in the pediatric intensive care unit.