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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
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.
Wasfy JH, Zigler CM, Choirat C, et al. Ann Intern Med. 2017;166:324-331.
Reducing hospital readmissions is an important patient safety objective. This pre–post study examined rates of hospital readmissions before and after the Centers for Medicare and Medicaid Services (CMS) enacted its nonpayment policy. Investigators separated hospitals into tiers of performance, considering hospitals with lowest readmission rates to be the highest performers. They found that across all levels of hospital performance, readmission rates for acute myocardial infarction, congestive heart failure, and pneumonia decreased after the Medicare Hospital Readmissions Reduction Program was introduced. Hospitals with the lowest performance prior to the nonpayment policy improved the most. These data are consistent with previous studies demonstrating the profound safety improvement following CMS nonpayment policies. A previous WebM&M interview discussed the potential benefits and limitations of insurers not paying for preventable complications.
Classen D, Munier W, Verzier N, et al. J Patient Saf. 2021;17:e234-e240.
The Medicare Patient Safety Monitoring System was developed to track adverse events nationally to support robust safety improvement. This review summarizes the history of the Medicare Patient Safety Monitoring System and its evolution into a new system that seeks to enhance the standardization and utilization of the collected data.
Wang Y, Eldridge N, Metersky ML, et al. J Am Heart Assoc. 2016;5.
Readmissions are subject to nonpayment by Medicare, but their use as a marker of quality is controversial. Experts have also raised concerns about the use of in-hospital mortality as a quality measure. Utilizing data from the AHRQ Medicare Patient Safety Monitoring System and the Centers for Medicare and Medicaid Services, this secondary analysis examined the link between rates of adverse events and rates of readmissions and 30-day mortality for patients treated for acute myocardial infarction in 793 hospitals. Investigators found that hospitals with a greater aggregate rate of adverse events also had higher readmission and mortality rates among patients with acute myocardial infarctions. Although readmission rates and mortality ratios have been criticized as inaccurate measures of the quality of care, the authors conclude that readmission and mortality rates do in fact reflect the quality of care in hospitals. A PSNet interview discussed the intersection of readmissions and quality.
Metersky M, Eldridge N, Wang Y, et al. J Hosp Med. 2016;11:276-82.
Anticoagulation medications are often associated with adverse drug events. This study found that less-than-daily monitoring of anticoagulation in hospitalized patients is associated with more frequent out-of-range values, suggesting that daily monitoring is safer.
Angus S, Vu R, Halvorsen AJ, et al. Academic medicine : journal of the Association of American Medical Colleges. 2014;89:432-5.
Examining whether medical school graduates are equipped to provide direct patient care in the beginning of their internships, this newspaper article reports how educators have collaborated to identify and integrate competencies, such as assertiveness and time management, to augment the safety of this transition.
Wang Y, Eldridge N, Metersky M, et al. N Engl J Med. 2014;370:341-51.
The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.
Metersky M, Hunt D, Kliman R, et al. Med Care. 2011;49:504-510.
Prior studies have raised the concern that minorities may be at higher risk of adverse events while hospitalized. This analysis of more than 100,000 hospital discharges found that black patients appeared to be at higher risk of hospital-acquired infections and certain adverse drug events. Interestingly, hospitals treating a higher proportion of black patients had higher rates of safety problems for all patients (regardless of race), implying that both patient factors and health care system factors may account for these disparities. Previous research has attempted to explore possible patient-level reasons for these findings.
Pham JC, Gianci S, Battles J, et al. Qual Saf Health Care. 2010;19:446-51.
Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.
Classen D, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21.
Adverse drug events (ADEs) are the most common type of errors in hospitalized patients. This study used data from the Medicare Patient Safety Monitoring System (which conducts detailed chart reviews of hospitalized Medicare patients) to arrive at national estimates for the incidence of ADEs in the Medicare patient population. Errors were common among patients receiving high-risk medications such as warfarin, insulin, and heparin—in fact, nearly 1 in 7 patients receiving heparin experienced an ADE. Medication errors were associated with an increased length of stay, as demonstrated in prior research. A related editorial discusses the MPSMS as an example of a patient-centered approach to detecting harmful errors. A case of an error associated with insulin prescribing is discussed in an AHRQ WebM&M commentary.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-34.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
O'Mahony S, Mazur E, Charney P, et al. J Gen Intern Med. 2007;22:1073-9.
The implementation of multidisciplinary rounds—collaborative meetings between medical staff, case managers, nurses, and other ancillary staff—was associated with significant improvements in performance on quality measures for pneumonia and congestive heart failure. Resident physicians felt the experience improved interdisciplinary communication and their knowledge of systems-based practice.