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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 - 11 of 11 Results
Lindberg C, Fock J, Nilsen P, et al. Scand J Caring Sci. 2022.
Providing in-home care for home-dwelling adults presents unique patient safety challenges. This qualitative study with 13 registered nurses in Sweden explored how nurses ensure safe home health care among home-dwelling older patients. Findings highlight the importance of continuity of care, trust between patients, caregivers, and nurses, and adapting safety requirements to meet environmental conditions and maintain a sense of home.
Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.
Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.
Lindblad M, Unbeck M, Nilsson L, et al. BMC Health Serv Res. 2020;20:289.
This study used a trigger tool to retrospectively identify and characterize no-harm incidents affecting adult patients in home healthcare settings in Sweden. The most common incidents identified by the trigger tool were falls without injury, medication management incidents, and moderate pain. Common contributing factors included delayed, erroneous, or incomplete nursing care and treatment.
Ericsson C, Skagerström J, Schildmeijer K, et al. BMJ Qual Saf. 2019;28:657-666.
Patient engagement in safety is considered a best practice and a National Patient Safety Goal, but less is known about patients' perceptions regarding this topic. In this survey study involving 1445 patients in Sweden, researchers found that more than 80% of respondents felt comfortable directing questions to doctors and nurses. Patients who had filed a formal complaint reporting a safety concern were found to believe with greater certainty that the patient perspective can improve the safety of care.
Schildmeijer KGI, Unbeck M, Ekstedt M, et al. BMJ Open. 2018;8:e019267.
In this study, researchers used trigger tools to identify adverse events among patients receiving home health care. They found that adverse events occurred frequently, were mostly preventable, and often led to patient harm in the form of extra health care resource utilization.
Skagerström J, Ericsson C, Nilsen P, et al. Nurs Open. 2017;4:230-239.
This qualitative study examines nurses' perspectives regarding patient engagement. Nurses reported that they believe health care workers and patients share responsibility for patient participation in care. Participants identified barriers to patient engagement, including time limitations, insufficient continuity with other providers, and lack of trust.
Lindblad M, Schildmeijer K, Nilsson L, et al. BMJ Qual Saf. 2018;27:502-511.
This study describes the development and validation of a trigger tool to identify possible adverse events among patients receiving home health care. The final result of 38 triggers with an overall positive predictive value of 41% suggests that this approach may be valid, if time-intensive, for safety work in home health care.
Rutberg H, Risberg MB, Sjödahl R, et al. BMJ Open. 2014;4:e004879.
Hospitals employ various methods to detect adverse events, each with their own advantages and drawbacks. In this study at an academic medical center, the Global Trigger Tool identified an adverse event rate of 20%, and only 6% of these cases were submitted to the voluntary reporting system.
Schildmeijer K, Nilsson L, Perk J, et al. BMJ Open. 2013;3:e003131.
Prior studies have found that the Global Trigger Tool has relatively poor interrater reliability for identifying adverse events. This qualitative study explored how teams of reviewers adapted the tool over time to increase reliability and utility of the tool.
Unbeck M, Schildmeijer K, Henriksson P, et al. Patient Saf Surg. 2013;7:10.
This comparison of two different methodologies for retrospectively detecting safety events found that the methodology used in the Harvard Medical Practice Study was more accurate than that used in the Global Trigger Tool.