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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 - 14 of 14 Results
Kane RL, Huckfeldt P, Tappen R, et al. JAMA Intern Med. 2017;177:1257-1264.
Reducing acute care hospitalizations from nursing homes is a patient safety priority. This cluster-randomized controlled trial compared a multimodal quality improvement intervention at long-term care facilities and found no difference in the rate of acute care hospitalizations compared to usual nursing home care. These results emphasize the challenge of improving safety outcomes in real-world clinical settings.
WebM&M Case December 1, 2013
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Wagner LM, Castle NG, Handler S. Geriatr Nurs. 2013;34:112-5.
Safety problems—particularly medication errors—are common in nursing homes and other long-term care settings. Prior studies have also shown that safety culture in long-term care settings is generally poor. One manifestation of poor safety culture can be that errors go unreported, and this survey of nearly 400 nursing homes found evidence confirming that substandard error reporting is a problem in long-term care. Few nursing homes surveyed used computerized methods to report errors or to monitor adverse event data, and respondents reported both technological and cultural barriers to voluntary error reporting. As most nursing homes also did not use computerized provider order entry or any other form of electronic medical record, the authors recommend more widespread adoption of health information technology in general, and error reporting systems specifically, in the long-term care setting. One such system for voluntarily reporting medication errors has been successfully implemented in nursing homes in North Carolina.
Castle NG, Wagner LM, Ferguson J, et al. Journal of Applied Gerontology. 2012;33.
In this study, nursing homes that received hand hygiene deficiency citations were more likely to have low staffing levels or to have received other citations for poor quality of care.
Kim H, Capezuti E, Kovner C, et al. Gerontologist. 2010;50:810-20.
Recent efforts to withhold payment for certain preventable adverse events have increased the importance of determining whether such conditions are present on admission to the hospital. This study found that, if the present-on-admission indicator was not used, the AHRQ Patient Safety Indicators overestimated the incidence of postoperative complications.
Castle NG, Wagner LM, Perera S, et al. J Patient Saf. 2010;64:59-67.
Measuring and improving the culture of safety are essential to safety improvement activities. AHRQ developed the Nursing Home Survey on Patient Safety Culture to specifically assess safety climate in this setting, where nursing home residents are vulnerable to a host of safety issues including medication errors. This study mirrored prior research in documenting an overall poor level of safety culture in a sample of 40 nursing homes. Administrators and managers had a more positive perception of safety culture than did frontline personnel, also similar to prior research. Suboptimal communication between nurses and physicians has been implicated as a driver of poor safety climate in nursing homes.