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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 - 19 of 19 Results
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. J Patient Exp. 2022;9:237437352211026.
Combining patient complaints and staff incident reports allows hospitals to better understand causes of patient harm. This children’s hospital designed a program to investigate serious experience events (SEE) modeled after their serious safety events (SSE) program. Through case studies, the authors describe how patient complaints were investigated to improve both patient experience and safety.
Mo Y, Eyre DW, Lumley SF, et al. PLoS Med. 2021;18:e1003816.
Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.
Avery AJ, Sheehan C, Bell BG, et al. BMJ Qual Saf. 2021;30:961-976.
Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.
Donnelly EA, Bradford P, Davis M, et al. CJEM. 2019;21:762-765.
While fatigue has been linked to safety-related outcomes in many healthcare settings, this link has not been definitively established in paramedicine. This article documents preliminary evidence—based on 717 surveys conducted in ten paramedic services in Ontario, Canada—of a relationship between fatigue and paramedic-reported safety outcomes and safety-compromising behaviors. The authors recommend fatigue mitigation efforts. 
Stocks SJ, Donnelly A, Esmail A, et al. BMJ Open. 2018;8:e020952.
Adverse events reported by patients are often different and more expansive than safety hazards identified by health care providers. Researchers elicited adverse events from a nationally representative sample of British outpatients. About 8% of patients reported an adverse event, which were frequently problems with medications, accessing care in a timely way, and diagnostic errors.
Pincavage A, Donnelly MJ, Young JQ, et al. Jt Comm J Qual Patient Saf. 2017;43:71-79.
Year-end handoffs in residency training settings are a known patient safety risk. This narrative review found that several practices can enhance the safety of year-end transitions, including standardizing written and verbal signout for high-risk patients and enhancing attending-level supervision.
Larson DB, Donnelly LF, Podberesky DJ, et al. Radiology. 2017;283:231-241.
Improving the culture of safety within health care is an essential component of preventing errors. This commentary discusses the culture of radiology in the context of recent progress in understanding and reducing diagnostic error. The authors suggest that peer-oriented feedback and assessment would drive progress in improving safety in radiology.
Stinnett-Donnelly JM, Stevens PG, Hood VL. BMJ Qual Saf. 2016;25:901-908.
This quality improvement project sought to prevent harmful or unnecessary care through a combination of electronic health record alerts and provider education. Three of five completed projects undertaken demonstrated success in reducing the unneeded intervention: fewer serum creatinine tests ordered in those with end stage renal disease, fewer portable chest radiographs ordered in the intensive care unit, and fewer bone-density scans ordered in average-risk women under age 65. The authors cite leadership support, frontline clinician engagement, and inclusion of trainees as factors that contributed to success of their interventions.

Kruskal JB, Kung JW, eds. Radiographics. 2015;35(6):1627-1848.

Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for providers and patients. Articles in this special issue explore noninterpretive skills in radiologic practice, such as root cause analysis, professionalism, and error identification and reduction.
Page DB, Donnelly JP, Wang HE. Crit Care Med. 2015;43:1945-1951.
Severe sepsis has been a focus of quality efforts. This retrospective study contrasted community-acquired sepsis with health care–associated sepsis. In line with definitions of health care–associated infections, investigators defined health care–associated severe sepsis as patients hospitalized with severe sepsis with an infection present at admission, where the patient was admitted from an inpatient nursing facility, was on hemodialysis, or was readmitted within 30 days to the same hospital. They separately considered hospital-acquired sepsis cases in which the patients did not have an infection at hospital admission. Both health care–associated and hospital-acquired sepsis, which together accounted for about one-third of cases, had a higher mortality rate and were more severe and costly than community-acquired severe sepsis. This adds to the evidence that health care–associated infections cause significant harm and costs to patients. In a related study, researchers examined readmissions following severe sepsis and found substantial variation in readmission rates, with an overall rate of about 20%, suggesting that targeting sepsis in readmission prevention efforts may be helpful.
Mardis T, Mardis M, Davis JJ, et al. J Nurs Care Qual. 2016;31:54-60.
Incomplete handoffs and poor communication regarding key clinical information may lead to adverse events. According to this systematic review, current research on bedside nursing handoffs suggests this method (conducting handoffs at the patient's bedside, instead of in a conference room or nurses' station) can improve patient and staff satisfaction, but evidence regarding its effect on patient safety is largely lacking.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

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