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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
Krein SL, Mayer J, Harrod M, et al. JAMA Intern Med. 2018;178:1016-1057.
Infection control precautions including use of personal protective equipment (PPE) are critical for preventing transmission of infections within health care settings. This direct observation study observed frequent failures in use of PPE, including entering rooms without using PPE at all, PPE process mistakes, and slips in properly executing PPE use. The authors suggest that given the wide range of failures, a variety of strategies are needed to improve use of PPE.
Fridkin SK, Baggs J, Fagan R, et al. MMWR Morb Mortal Wkly Rep. 2014;63:194-200.
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
Tinoco A, Evans S, Staes CJ, et al. J Am Med Inform Assoc. 2011;18:491-7.
This study found that computerized surveillance systems detected more hospital-acquired infections than manual chart review, but both methods detected similar rates of adverse drug events. The authors discuss the tradeoffs of each surveillance method and highlight how each system used information from different sources.
Weissman JS, Rothschild JM, Bendavid E, et al. Med Care. 2007;45:448-55.
… Medical care … Med Care … Past research suggests a relationship between nursing workload and quality of care … hospital workload and adverse events and discovered that a hospital operating consistently near capacity had increased … only one of the sites. At this site, they estimated that a 10% increase in occupancy led to a 15% increase in adverse …
Evans S, Lloyd JF, Stoddard GJ, et al. Ann Pharmacother. 2005;39:1161-8.
… factors, such as specific patient characteristics. Using a logistic regression model, investigators discovered several … For instance, drug administration route represented a significant risk factor for all ADEs. The article includes …
Bennett CL, Nebeker JR, Lyons A, et al. JAMA. 2005;293:2131-40.
This article summarizes the structure, funding, organization, and methods of an independent and clinically based surveillance program identifying serious and unrecognized adverse drug events (ADEs). The authors provide a detailed account of the process involved, from investigating a possible serious ADE to disseminating their findings to the Food and Drug Administration (FDA), manufacturers, conferences, journals, and the news media. They also share initial results of their operations with details of 16 drugs associated with serious ADEs, including tabular display of the cases reported and the inconsistencies in the dissemination of safety information. The authors conclude by sharing potential implications of the program’s efforts and how this surveillance method may provide additional opportunity to detect and prevent serious ADEs.
Samore MH, Evans S, Lassen A, et al. JAMA. 2004;291:325-34.
This study evaluated methods for medical device event surveillance to help identify and classify an important source of adverse events. Investigators used a number of different strategies to capture device-related events, which included a computer-based system, discharge codes (ICD-9), work logs, and patient survey results. They analyzed more than 7000 identified problems and discovered that very few events were captured by more than one surveillance strategy. Their findings suggest that voluntary reporting alone vastly underestimates the rate of medical device-related errors. Furthermore, future investigation to better understand the incidence and nature of such events must occur to frame necessary prevention efforts.