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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 - 18 of 18 Results
Cifra CL, Westlund E, Ten Eyck P, et al. Diagnosis (Berl). 2020;8:193-198.
Missed sepsis diagnosis can lead to increased morbidity, mortality and length of stay. Using administrative data, this retrospective study estimated the risk of potentially missed pediatric sepsis in several emergency departments. Approximately 8% of pediatric patients admitted to the hospital with sepsis experienced a treat-and-release emergency department visit within the prior 7 days. Administrative data can be helpful for hospitals in identifying cases that require detailed record review as well as evaluating the impact of sepsis alerts and bundles.
Baloh J, Zhu X, Ward MM. Med Care Res Rev. 2021;78:146-156.
Organizational factors often play a major role in determining whether the implementation and sustainment of safety improvement initiatives are successful. Researchers studied the implementation of TeamSTEPPS across 10 rural hospitals. They found that five of the hospitals sustained facilitation activities crucial for implementation and cite senior management support, middle management support, and team continuity as organizational factors necessary for sustainment.
Natafgi N, Baloh J, Weigel P, et al. The Journal of Rural Health. 2016;33.
Critical access hospitals are located in rural areas, at least 35 miles from any other hospital. Prior studies found these hospitals may have worse outcomes for patients with acute myocardial infarction, congestive heart failure, or pneumonia, compared with other acute care hospitals. Using data from the Healthcare Cost and Utilization Project and American Hospital Association, this study examined surgical outcomes from 136 nonfederal general hospitals with fewer than 50 beds. Following adjustments for patient mix, hospital characteristics, and number of discharges, investigators found no differences in surgical patient safety indicators between critical access rural hospitals and comparably sized prospective payment hospitals. This finding demonstrates the importance of quality surgical care in rural hospitals. An AHRQ-funded toolkit provides resources for small rural hospitals interested in implementing safety measures.
Wakefield DS, Ragan R, Brandt J, et al. Jt Comm J Qual Patient Saf. 2012;38:243-53.
Efforts to improve communication are an ongoing challenge in patient safety, particularly among providers during handoffs. Current strategies being employed include adopting structured communication tools, implementing interdisciplinary rounds, and using patient whiteboards. This study implemented bedside nursing handoffs at shift change as a patient-centered approach to reducing communication gaps. Following implementation, there were significant improvements in nursing-sensitive patient satisfaction scores compared with other nonparticipating units, though the sustainability declined after the first 6 months. The authors describe the important planning that must precede such an intervention and the barriers associated with nursing resistance to bedside shift reports. Like many quality improvement efforts, ongoing monitoring and repeat interventions are required.
Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.
Verbal orders, usually for medications, are commonly used in the inpatient setting despite being a recognized source of error. This survey of 40 hospitals found wide variation in hospital policies regarding verbal orders, with no uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, are endorsed for improving the reliability of verbal orders, few hospitals specifically mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this AHRQ WebM&M commentary.
Roberts LL, Ward MM, Brokel JM, et al. Am J Health Syst Pharm. 2010;67:1838-46.
A computerized provider order entry system combined with decision support identified more potential adverse drug events compared to hospitals using only decision support. However, 94% of the potential adverse drug events were found to be false positives after review by a pharmacist.
Wakefield DS, Ward MM, Loes JL, et al. J Am Med Inform Assoc. 2010;17:584-7.
Uptake of health information technology has been slow, especially in smaller hospitals and ambulatory practices. This article describes the successful implementation of an electronic medical record in a group of rural and critical access hospitals.
Piontek F, Kohli R, Conlon P, et al. Am J Health Syst Pharm. 2010;67:613-20.
Computerized monitoring and alerts for adverse drug events (ADEs) are strategies adopted by hospitals to prevent medication errors. This retrospective observational study evaluated the impact of an ADE alert system in seven community hospitals; two network hospitals that did not implement the system served as controls. Investigators found that adoption of the ADE alert system led to significant decreases in pharmacy department costs, variable drug costs, and severity-adjusted mortality rates in the post-implementation period. In contrast, pharmacy department costs and drug costs increased significantly in the two network hospitals without an alert system over the same time period. The authors suggest that their findings support the potential benefits of an ADE alert system in the community hospital setting.
Perspective on Safety April 1, 2010
… its lenses of expert consensus and scientific evidence. … Lance L. Roberts, MS … Data Coordinator Iowa Healthcare Collaborative …
Over the last decade, considerable attention has focused on addressing deficiencies associated with health care quality and patient safety performance in the United States.
Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a private, not-for-profit organization established in 1999 to develop and implement a national strategy for health care quality measurement and reporting.
Vartak S, Ward MM, Vaughn TE. J Rural Health. 2010;26:58-66.
This article found that the incidence of specific safety problems (as measured by the AHRQ Patient Safety Indicators) was similar for both small urban and small rural hospitals. A toolkit for implementing safety measures in rural hospitals has been published previously.
Halbesleben JRB, Wakefield BJ, Wakefield DS, et al. West J Nurs Res. 2008;30:560-77.
This study adds to past efforts that demonstrated a significant relationship between nurse burnout and patient safety. Although burnout was not associated with event reporting, investigators did find lower perceptions of safety in analyzing results from the AHRQ Hospital Survey on Patient Safety Culture.
Ward MM, Evans TC, Spies AJ, et al. Am J Med Qual. 2006;21:101-8.
This study assessed a representative group of hospitals to evaluate their perception and priority of each of the National Quality Forum's (NQF) 30 "safe practices." Investigators analyzed responses from 100 hospitals and determined higher ratings for priority than for progress of the practices overall. They noted the largest discrepancy between priority and progress in creating a safety culture with the highest progress rating for increasing safe medication use. Based on evaluating individual hospital characteristics, the authors also identified 20 safe practices not associated with measures of hospital structure, capacity, or resources. These particular findings may guide other organizations trying to develop strategic safety plans with respect to NQF safety recommendations.