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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 39 Results
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.
Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.
… for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of … The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective . … Coffey M, Marino M, Lyren A, et al. …
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.
Profit J, Sharek PJ, Cui X, et al. J Patient Saf. 2020;16:e310-e316.
Prior research has shown that health care worker perceptions of safety culture may vary across different neonatal intensive care units (NICUs). Less is known as to how perceptions of NICU safety culture relate to NICU quality of care. In this cross-sectional study involving 44 NICUs, researchers found a significant relationship between safety climate and teamwork ratings and a lack of health care–associated infections, but no relationship with regard to the other performance metrics examined in the study.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Jt Comm J Qual Patient Saf. 2019;45:164-169.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … High … safety culture , and robust process improvement. A past PSNet interview discussed high reliability as it … Randall KH, Slovensky D, Weech-Maldonado R, Patrician PA, Sharek PJ. Self-Reported Adherence to High Reliability …
Caruso TJ, Munshey F, Aldorfer B, et al. Jt Comm J Qual Patient Saf. 2018;44:552-556.
Surgical time outs are a required practice prior to incision. This project report discusses the design and testing of an additional step before performing the time out in pediatric surgical cases. The authors found the innovation to be widely accepted by perioperative teams, demonstrating its potential to support safe care.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
… Pediatrics … Pediatrics … This study used a trigger tool (the Global Assessment of Pediatric Patient … this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to … be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more …
Stockwell DC, Landrigan CP, Schuster MA, et al. Pediatr Qual Saf. 2018;3:e081.
The Centers for Medicare and Medicaid Services (CMS) has successfully reduced preventable harm from hospital-acquired conditions (HACs) through financial penalties to hospitals. Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list, raising concern about whether institutions may be neglecting other types of preventable harm. Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list. Only 58 of 240 harms were considered HACs. Some common harms identified outside the scope of HACs were intravenous catheter infiltration, surgical complications, and pain. Prior WebM&M commentaries have discussed harms from hospital-acquired infections as well as the unintended consequences of public hospital quality reporting.
Bhat PN, Costello JM, Aiyagari R, et al. Cardiol Young. 2018;28:675-682.
Researchers surveyed pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United States. More than 80% of respondents perceived diagnostic errors to be common and 65% reported errors causing permanent harm to patients. Improving feedback and teamwork were frequently suggested as strategies for reducing diagnostic error.
Stockwell DC, Bisarya H, Classen D, et al. J Patient Saf. 2016;12:180-189.
Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.
Profit J, Lee HC, Sharek PJ, et al. BMJ Qual Saf. 2016;25:954-961.
Health care organizations measure safety climate by surveying providers and staff at all levels. Investigators assessed safety culture and teamwork in 44 neonatal intensive care units using two different survey tools—the Safety Attitudes Questionnaire and the Hospital Survey on Patient Safety Culture. They found significant variation in safety and teamwork climate scales of both tools, indicating that the instruments should not be used interchangeably.
Bennett SC, Finer N, Halamek LP, et al. Jt Comm J Qual Patient Saf. 2016;42:369-76.
Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.
Stone S, Lee HC, Sharek PJ. Jt Comm J Qual Patient Saf. 2016;42:309-315.
This implementation study examined factors that affect sustained improvement associated with an intervention to increase the rate of premature infants receiving breast milk. Investigators found that physician involvement and continuous education contributed to maintaining the intervention. Human factors efforts such as incorporating the intervention into daily workflow and providing feedback also supported this safety practice.
Stockwell DC, Bisarya H, Classen D, et al. Pediatrics. 2015;135:1036-42.
… Pediatrics … Pediatrics … Trigger tools are widely used as a means of detecting adverse events , but most of the … adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on … for Healthcare Improvement's Global Trigger Tool . In a retrospective chart review across six academic children's …
Caruso TJ, Marquez JL, Wu DS, et al. Jt Comm J Qual Patient Saf. 2015;41:35-42.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This before-and-after study demonstrated that implementing a standardized handoff process called I-PASS between the operating room and the postanesthesia care …
Bigham MT, Logsdon TR, Manicone PE, et al. Pediatrics. 2014;134:e572-e579.
Discontinuity between providers is a well-known source of errors, with problems arising from handoffs and signouts both in hospital and at hospital discharge. This quality improvement initiative aimed to enhance handoffs in 23 children's hospitals over a 12-month period. Following introduction of a structured handoff tool, handoff-related care failures declined and provider satisfaction with handoffs increased. Handoff-related care failures were defined as insufficient information transfer that affected the patient, such as reporting inaccurate test results or miscommunication that led to duplicated medications. This study is the largest to date of a standardized handoff approach, and these results are consistent with prior smaller studies. A past AHRQ WebM&M commentary describes pitfalls of handoffs.