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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 - 12 of 12 Results
Smith KJ, Handler S, Kapoor WN, et al. Am J Med Qual. 2016;31:315-22.
Medication inconsistencies are common at hospital discharge. This study found that computerized discharge medication reconciliation, combined with automatic communication of the reconciled medication list to the patient's primary care physician, reduced discharge medication errors.
D'Amour D, Dubois C-A, Tchouaket E, et al. Int J Nurs Stud. 2014;51:882-91.
Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.
Olds DM, Clarke S. J Safety Res. 2010;41:153-62.
A considerable amount of attention has been paid to the issue of physician work hours and patient safety, thanks in part to regulations limiting duty hours for resident physicians. Fatigue has also been demonstrated to be a risk factor for errors among nurses, particularly when nurses work overtime or extended duration shifts. In this analysis, the authors found that among nurses, working voluntary overtime or working more than 40 hours per week were strongly correlated with an increase in self-reported errors, particularly needlestick injuries and medication errors. While legislative efforts have focused on restricting mandatory overtime for nurses, these results raise concern that the widespread practice of taking voluntary overtime shifts could negatively affect patient safety.
Aiken LH, Clarke S, Sloane DM, et al. JAMA. 2002;288:1987-93.
… The outcomes are risk-adjusted and representative of a diverse collection of hospitals and surgical patients (eg, … orthopedic, and vascular). The authors conclude that a commitment to adequate nursing care may prevent adverse … and improve nurse retention and satisfaction. … Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse …
Aiken LH, Clarke S, Cheung RB, et al. JAMA. 2003;290:1617-1623.
This study examines the relationship between nursing educational levels and patient outcomes using cross-sectional analyses of outcomes data. Investigators studied more than 230,000 general, orthopedic, and vascular surgery patients discharged from 168 Pennsylvania hospitals. Results showed lower mortality rates in hospitals with higher levels of nursing education after adjustment for patient and hospital characteristics, as well as nursing factors. The authors suggest greater emphasis on nursing education, nursing workforce planning, and adequate financing to support these efforts nationally with the ultimate goal of improving patient care.