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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 - 9 of 9 Results
Halpin HA, McMenamin SB, Simon LP, et al. Am J Infect Control. 2013;41:307-11.
This study demonstrated that hospitals participating in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) had significant improvements in adoption and implementation of evidence-based patient safety practices. However, there were no differences in health care–associated infection rates compared with non-CHAIPI hospitals.
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.
Weiner BJ, Alexander JA, Baker LC, et al. Med Care Res Rev. 2006;63:29-57.
This AHRQ-funded study describes the association between dimensions of effective quality improvement (QI) and their impact on hospital-based patient safety indicators (PSI). Investigators combined data from a national survey of hospital QI practices with four PSIs in demonstrating that physician involvement in QI was the only significant association with improved indicator scores. Involvement of senior management and multiple hospital units in a QI effort failed to demonstrate a significant association with PSI values. This study expands on previous efforts at understanding the organizational factors involved in achieving patient safety improvement.
Walshe K, Shortell SM. Health Aff (Millwood). 2004;23:103-11.
The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the Bristol Royal Infirmary cardiac surgery scandal—to determine the nature of the system factors that resulted in patient harm.  In most cases, problems were well known, but not addressed, indicating pervasive problems with safety culture and barriers to reporting and investigation of such incidents.  The authors call for improvements in reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures.