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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 45 Results
O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;176:1456-1464.
Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.
Terwilliger IA, Johnson JK, Manojlovich M, et al. Jt Comm J Qual Patient Saf. 2024;50:193-201.
Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
O'Leary KJ, Manojlovich M, Johnson JK, et al. Jt Comm J Qual Patient Saf. 2020;46:667-672.
Teamwork is essential to providing high quality, safe healthcare. This survey of general medicine nurses, nurse assistants, and physicians at four hospitals identified significant differences in perceptions of teamwork climate and collaboration across professional categories. While a majority of physicians reported the quality of collaboration with nurses as high, less than half of nurses gave high ratings to the quality of collaboration with physicians. Future teamwork training efforts should target the discrepancy in perceived teamwork across professional categories.
Auerbach AD, O'Leary KJ, Greysen SR, et al. J Hosp Med. 2020;15:483-488.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).
O'Leary KJ, Johnson J, Manojlovich M, et al. Jt Comm J Qual Patient Saf. 2017;43:573-579.
Previous studies have investigated the benefits of unit-based interventions as a potential safety strategy. This survey study sought to examine implementation of several unit-based initiatives to improve care quality in inpatient settings: localization of physicians to specific designated units, nurse–physician joint leadership, periodic review of local performance data, and interdisciplinary rounds. Investigators invited residency program directors and hospital medicine leaders to participate in the study. The response rate was low and thus the findings may not reflect academic hospitals in general. Overall, among respondents' institutions, the interventions were not widely or consistently implemented. These findings underscore the challenge of translating interventions shown to be effective for enhancing safety in research settings into clinical practice.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43:433-447.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Burke RE, Schnipper JL, Williams M, et al. Med Care. 2017;55:285-290.
This retrospective cohort study demonstrated that a readmission risk score could prospectively identify patients at risk for readmissions for the four target conditions for nonpayment: acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure. These results suggest that this algorithm can identify a high-risk patient group who may benefit from interventions to prevent readmission.
Greysen R, Harrison JD, Kripalani S, et al. BMJ Qual Saf. 2017;26:33-41.
Hospitals with high readmission rates face reductions in Medicare reimbursements. Understanding the patient perspective at the time of readmission may better inform future readmission reduction efforts. Researchers surveyed patients readmitted to the general medicine services within 30 days of discharge across 12 hospitals on multiple aspects of self-care. Although 91% of patients reported understanding of their discharge plan, more than 52% reported difficulty with at least one aspect of self-care after discharge.
Schaefer EW, Williams M, Zee PC. J Hosp Med. 2012;7:489-96.
Given that hospitalized patients require 24-hour access to clinicians, management of fatigue due to shift work is an important consideration for overnight care teams. Discussing the physiological impacts of working during typical sleep time, or circadian misalignment, this review explores on-site naps, appropriate caffeine intake, and light exposure as techniques hospitalists can utilize to manage the negative effects associated with sleep disruption. A PSNet perspective described how fatigue can affect physician performance.
Auerbach AD, Kripalani S, Vasilevskis EE, et al. JAMA Intern Med. 2016;176:484-93.
Preventing readmissions is a cornerstone of patient safety efforts. However, one concern about nonpayment for readmissions is that many may not be preventable. To determine whether they were preventable, this observational study investigated readmissions through patient and physician surveys along with chart review. Researchers determined that only one quarter of readmissions were preventable. Factors associated with potential preventability were premature hospital discharge, insufficient communication with outpatient providers, failure to discuss care goals, and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple interventions will be needed to avert readmissions, and such efforts will have limited impact since most readmissions are not preventable.
Phatak A, Prusi R, Ward B, et al. J Hosp Med. 2016;11:39-44.
Medication errors are a common cause of adverse events after hospital discharge. This randomized controlled trial found that integrating pharmacists into the discharge process improved patient satisfaction and reduced adverse drug events, emergency department visits, and readmissions in the 30 days after discharge. Pharmacists conducted medication reconciliation, provided patient education, and had multiple telephone contacts with patients after discharge.
O'Leary KJ, Killarney A, Hansen LO, et al. BMJ Qual Saf. 2016;25:921-928.
Interprofessional bedside rounds have been promoted as a way to enhance patient-centeredness, but their benefits remain unclear. This randomized trial of patient-centered bedside rounding found no differences in patient satisfaction outcomes. Nurses perceived bedside rounds to improve communication, but physicians did not. This raises questions about the benefits of patient-centered bedside rounds as a way to improve patient satisfaction and suggests further research is needed to identity methods to augment patient-centered care.
Li J, Boulanger B, Norton J, et al. Jt Comm J Qual Patient Saf. 2015;41:494-501.
Root cause analyses (RCAs) are widely employed at hospitals for exploring safety events. However, RCAs may not always be effective, and recent guidelines issued by the National Patient Safety Foundation highlighted the importance of emphasizing actions to address root causes. This study describes the development of a new rapid approach to RCAs, colloquially called "SWARMing," based on the concept of swarm intelligence. SWARMs are conducted without delays after a reported event. The process begins with a preliminary investigation into what happened and who was involved, followed by an in-person meeting with an interdisciplinary team and any staff directly involved in the event. The authors describe the key structure and steps of their SWARM program, including the focus on actions and accountability. Following the implementation of SWARMs, incident reporting increased by 52%. At the same time, the observed-to-expected mortality ratio decreased 37% from 1.2 to 0.7 across the health system, suggesting the program had a significant effect.
O'Leary KJ, Turner J, Christensen N, et al. J Hosp Med. 2015;10:147-51.
Clinician discontinuity is often cited as a potential patient safety issue. However, this study found that transfers of care between hospitalists did not appear to be associated with adverse events. The authors note that as hospital care is provided within teams, research should focus on the effects of team complexity and changes on patient safety.
Merkow RP, Ju MH, Chung JW, et al. JAMA. 2015;313:483-495.
Hospital readmissions have received intensive focus lately, largely compelled by Medicare's expanded financial penalties for excessive readmission rates. This study reviewed 30-day readmissions following surgery at hospitals enrolled in the National Surgical Quality Improvement Program. Nearly half a million operations were included, with an overall readmission rate of 5.7%. Following lower extremity vascular bypass, approximately 1 in 7 patients were readmitted. Surgical site infections accounted for the largest proportion of overall readmissions. It is notable that only 2% of patients were readmitted for the same complication that prompted their index admission, further confirming that surgical readmissions are overwhelmingly due to new complications arising from the procedure. In an accompanying editorial, Dr. Lucian Leape notes that analyses of these surgical complications can serve as "treasures" for providing important lessons for improvement, and he calls for a 50% reduction in surgical complication rates in the near term.
Williams M, Li J, Hansen LO, et al. South Med J. 2014;107:455-65.
This qualitative study of a large-scale quality improvement effort to reduce readmissions and adverse events after discharge identified numerous barriers to implementing the project as well as several facilitators of success. Intensive mentoring by project champions appeared to be a key factor in success of the program.