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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 36 Results
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.
Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.
Wang JS, Fogerty RL, Horwitz LI. PLoS One. 2017;12:e0186075.
This secondary data analysis found that most patients admitted to the hospital have their medications changed to another medication of the same class to be consistent with the hospital formulary. Researchers found that patients who undergo this therapeutic interchange are more likely to have errors in medication reconciliation at the time of hospital discharge compared to patients whose medications are not changed. The authors suggest that improved information technology may address this patient safety concern.
Krumholz HM, Wang K, Lin Z, et al. N Engl J Med. 2017;377:1055-1064.
Avoiding readmissions has been an important safety goal, especially since Medicare has implemented nonpayment policies. Patient factors like health literacy and access to outpatient follow-up care have been implicated in previous research on readmissions. In contrast, this study sought to determine whether hospital quality affects readmission rates. By examining patients with multiple admissions for the same diagnosis but at different hospitals, they were able to focus on the effect of the hospital alone. Hospitals were divided into four tiers based on their known overall rate of readmissions, and then investigators assessed whether a given patient was more or less likely to be readmitted based on these tiers. They found a higher likelihood of a given patient being readmitted at hospitals in the tier with the most readmissions compared to those hospitals in the lowest readmission tier. The authors conclude that hospital readmissions are in part due to hospital factors as well as individual factors. This finding suggests that targeting hospital safety practices could reduce readmissions.
Dharmarajan K, Wang Y, Lin Z, et al. JAMA. 2017;318:270-278.
Reducing hospital readmissions is a major patient safety priority. The Centers for Medicare and Medicaid Services policy of nonpayment for readmissions for certain conditions has decreased their incidence. However, the impact of this policy on 30-day postdischarge mortality remains unknown. Researchers conducted a retrospective study of Medicare fee-for-service patients admitted to hospitals with heart failure, acute myocardial infarction, or pneumonia from 2008 through 2014. They calculated monthly 30-day risk-adjusted readmission rates and 30-day risk-adjusted mortality rates for each condition at each hospital. They then examined the association between hospitals' monthly trends in 30-day readmissions and 30-day mortality after discharge for each condition. The authors found a weak but significant association between decreased 30-day readmissions and lower 30-day postdischarge mortality and conclude that efforts to reduce readmissions for the analyzed conditions do not lead to increased mortality. A previous WebM&M commentary discussed an incident involving a patient readmitted to the hospital after being discharged to a skilled nursing facility.
Desai NR, Ross JS, Kwon JY, et al. JAMA. 2016;316:2647-2656.
This retrospective analysis of Medicare claims data found that the decrease in readmissions following the Hospital Readmission Reduction Program occurred across target conditions and other diagnoses. Hospitals penalized by the Centers for Medicare and Medicaid Services had greater reductions in readmissions for the targeted conditions. These results support the effectiveness of the nonpayment policy.
Denson JL, Jensen A, Saag HS, et al. JAMA. 2016;316:2204-2213.
Handoffs are ubiquitous in hospital care and a recognized risk factor for adverse events. Most research on handoffs has focused on care transitions from the primary clinician to a covering clinician, but studies have also demonstrated the potential for harm associated with changes in the entire team of care (such as at the end of the academic year). In academic hospitals, clinician teams switch on a predictable schedule, often at the end of the month, when residents complete a rotation. This study analyzed the outcomes of more than 200,000 inpatients at Veterans Affairs hospitals to determine if end-of-rotation team changes were associated with clinical harm. Investigators found a striking increase in in-hospital mortality among patients whose hospitalization spanned the end of a rotation (and thus were exposed to a resident team change during their hospital stay), which persisted for up to 90 days after discharge. The accompanying editorial notes that some of the mortality increase may be accounted for by the fact that patients who are more seriously ill and have longer hospitalizations may have been at higher risk of death independent of the team change. Nevertheless, since there are no standards for patient handoffs at the end of a rotation, poor information transfer or cognitive heuristics (such as anchoring bias) may have led to preventable adverse events. The editorial authors advocate for more research into the mechanisms of this mortality increase and the development of standards analogous to the I-PASS signout format for end-of-rotation handoffs.
Wang Y, Eldridge N, Metersky ML, et al. J Am Heart Assoc. 2016;5.
Readmissions are subject to nonpayment by Medicare, but their use as a marker of quality is controversial. Experts have also raised concerns about the use of in-hospital mortality as a quality measure. Utilizing data from the AHRQ Medicare Patient Safety Monitoring System and the Centers for Medicare and Medicaid Services, this secondary analysis examined the link between rates of adverse events and rates of readmissions and 30-day mortality for patients treated for acute myocardial infarction in 793 hospitals. Investigators found that hospitals with a greater aggregate rate of adverse events also had higher readmission and mortality rates among patients with acute myocardial infarctions. Although readmission rates and mortality ratios have been criticized as inaccurate measures of the quality of care, the authors conclude that readmission and mortality rates do in fact reflect the quality of care in hospitals. A PSNet interview discussed the intersection of readmissions and quality.
Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf. 2016;25:e7.
The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.
Chen SI, Fox ER, Hall K, et al. Health Aff (Millwood). 2016;35:798-804.
Drug shortages have been a persistent problem for several years and have been shown to affect patient safety. The Food and Drug Administration Safety and Innovation Act of 2012 was intended to address these shortages. This analysis found that while shortages have decreased since the act was passed, problems with drug supply for acute care facilities remain.
Jenq GY, Doyle MM, Belton BM, et al. JAMA Intern Med. 2016;176:681-90.
Reducing readmissions has become a central target for hospitals, mostly spurred by Medicare policies that penalize excessive readmission rates. Although some intensive programs have successfully avoided readmissions, many other efforts have failed. This study at an urban academic medical center involved targeting only high-risk patients and providing them with a personalized transitional care plan that included detailed medication reconciliation and follow-up phone calls, as well as linking them with community resources. Over a 2-year period, the readmission rate dropped from 21.5% to 19.5% in the intervention group and from 21.1% to 21.0% in the control population. This 9% relative reduction in readmissions is significant, though it translates to a number-needed-to-treat of 50 (to avoid 1 readmission), which is quite high for a resource-intensive intervention. A prior PSNet perspective discussed strategies for reducing hospital readmissions.
Metersky M, Eldridge N, Wang Y, et al. J Hosp Med. 2016;11:276-82.
Anticoagulation medications are often associated with adverse drug events. This study found that less-than-daily monitoring of anticoagulation in hospitalized patients is associated with more frequent out-of-range values, suggesting that daily monitoring is safer.
Schuster KM, Jenq GY, Thung SF, et al. J Am Med Inform Assoc. 2014;21:e352-e357.
A computerized physician sign-out note embedded into the electronic medical record was designed at Yale–New Haven Hospital to facilitate patient handoffs. This study found that many non-physician health professionals have also been using the sign-out tool, which is felt to be an unintended positive consequence of the system.
Wang Y, Eldridge N, Metersky M, et al. N Engl J Med. 2014;370:341-51.
The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.
Schoenfeld AR, Al-Damluji MS, Horwitz LI. BMJ Qual Saf. 2014;23:66-72.
Despite use of a standardized template, the inclusion of key data elements in inpatient signouts varied widely between specialties in this study conducted at a tertiary care teaching hospital. The authors attribute this finding to cultural differences across specialties and acknowledge that a one-size-fits-all approach to signouts may not be appropriate.
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. J Hosp Med. 2013;8:609-14.
Despite consensus that the signout process between physicians should be standardized to reduce the risk of errors, the utility of written versus verbal signouts is still under investigation. Much research on effective signout techniques has focused on handoffs between residents, with comparatively little data on signouts between attending physicians. This descriptive study of hospitalists' signouts found that most hospitalists relied primarily on the signout to respond to overnight questions and consulted electronic medical records or other data sources less frequently. However, the utility of the written signout varied widely despite use of a template—for example, the written signout was not particularly helpful in assessing possible changes in a patient's clinical status. Given that information transfer with verbal signout has also been shown to be inadequate, this study indicates a need to further optimize both verbal and written signouts. An AHRQ WebM&M perspective discussed the current knowledge base regarding safe transitions of care for inpatients.
Ziaeian B, Araujo KLB, Van Ness PH, et al. J Gen Intern Med. 2012;27:1513-1520.
Medication discrepancies remain common at hospital discharge, despite intense efforts to improve medication reconciliation processes. Conducted in a geriatric patient population, this prospective cohort study found a similar incidence of medication discrepancies at discharge compared with prior studies, but concerningly, patients were unaware of most of these errors. Both provider errors and patient misunderstanding occurred more frequently for medications prescribed for conditions other than the primary hospital diagnosis, indicating that disease-specific efforts to improve medication safety may miss many errors.