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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 - 20 of 23 Results
Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.
Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.
Abbas M, Robalo Nunes T, Martischang R, et al. Antimicrob Resist Infect Control. 2021;10:7.
The large burden placed on hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This narrative review summarizes existing reports on nosocomial outbreaks of COVID-19 and the strategies health systems have implemented to control healthcare-associated outbreaks. The authors found little evidence describing the role of healthcare workers in reducing or amplifying infection transmission in healthcare settings.  
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.
Boockvar K, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.
Inaccurate medication reconciliation leads to medication discrepancies and places patients at risk for adverse drug events. Health information exchange can enhance medication safety through improved access to prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access to a regional health information exchange for patients admitted to a single hospital in the intervention arm and without such information access for patients in the control arm. In the first 10 months of the study, the health information exchange provided access to prescribing information from large hospitals and a pharmacy insurance plan, but only hospital prescribing information was available during the last 21 months because the insurance plan began charging for data. Although researchers found no significant difference between the intervention and control groups with regard to the number of medication discrepancies, patients who underwent medication reconciliation with access to pharmacy insurance data had a higher number of medication discrepancies identified than control patients. They conclude that charging for pharmacy data interrupted the positive effect of health information exchange on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing information led to an adverse drug event.
Mull HJ, Rosen AK, Shimada SL, et al. EGEMS (Wash DC). 2015;3:1116.
Trigger tools have been shown to be an efficient way to screen for adverse events. This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient setting. Five of the triggers performed reasonably well for either detecting harm or leading to a change in care plan.
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.
Huskins C, Huckabee CM, O'Grady NP, et al. N Engl J Med. 2011;364:1407-18.
Antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecalis (VRE), are frequent sources of hospital-acquired infection (HAI) in the intensive care unit (ICU). Although the incidence of serious infections caused by MRSA has been decreasing, the optimal strategies to prevent spread of these bacteria remain unclear. In this cluster-randomized trial conducted in 18 ICUs, a protocol that involved universal surveillance and barrier precautions (gowns and gloves) for patients colonized with these bacteria was evaluated for effectiveness at preventing colonization and infection with MRSA or VRE. No reduction in colonization or infection was found, in part attributable to the fact that use of barrier precautions was suboptimal. Prior successful efforts to reduce HAI have emphasized the role of safety culture in addition to specific preventive interventions, an approach discussed in-depth in this analysis of the landmark Keystone ICU project.
Boockvar K, Blum S, Kugler A, et al. Arch Intern Med. 2011;171:860-1.
This study found that medication reconciliation at hospital admission successfully reduced adverse drug events (ADEs) caused by incorrect admission medication changes. However, the investigators found that appropriate admission medication changes (e.g., withholding antihypertensive medication in a patient presenting with low blood pressure) were also associated with subsequent ADEs, indicating a need for better medication monitoring during hospitalization.
Harbarth S, Fankhauser C, Schrenzel J, et al. JAMA. 2008;299:1149-57.
Patients who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at risk for infections, particularly after undergoing surgery, and may also transmit the bacteria to other patients if hospital staff do not follow proper infection control practices. This study evaluated one widely advocated strategy for reducing MRSA infections: screening all patients for MRSA at admission. Although the hospital had a relatively high rate of MRSA colonization, the intervention did not reduce nosocomial MRSA infections. Despite these results, universal screening for MRSA is likely to become increasingly common in hospitals, as several states have passed legislation mandating this practice.
Zhan C, Arispe IE, Kelley E, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;31.
This AHRQ–funded study estimates the national prevalence of adverse drug events by capturing data from outpatient physician visits. Using survey data, investigators report on more than 4 million office visits associated with a diagnostic code for an adverse drug event. Although upward trends over time were not statistically significant, the authors conclude that their findings and methods may offer a mechanism for continued tracking of this important safety concern on a national level.
Evans S, Lloyd JF, Stoddard GJ, et al. Ann Pharmacother. 2005;39:1161-8.
Many medications remain at risk for producing an adverse drug event (ADE) despite proper ordering and administration. This study examined more than 4300 ADEs to determine potential risk factors, such as specific patient characteristics. Using a logistic regression model, investigators discovered several risk factors that were present across drug classes with others that remained class-specific. For instance, drug administration route represented a significant risk factor for all ADEs. The article includes detailed tables outlining ADEs captured and risk factors by drug category. The authors conclude that high-risk drugs, as well as high-risk patient and drug administration characteristics, should be vigilantly monitored.
Nebeker JR, Hoffman JM, Weir C, et al. Arch Intern Med. 2005;165:1111-6.
With growing adoption of information technology systems designed to improve the safety and quality of care, this study prospectively evaluated the incidence and epidemiology of adverse drug events (ADEs) in a computerized inpatient setting. After implementation of electronic resources at a Veterans Administration hospital (eg, electronic medical records [EMRs], computerized provider order entry [CPOE], integrated checking of allergies and drug-drug interactions, and bar coding), pharmacists identified and categorized nearly 500 ADEs over a five-month period. Results suggested that 25% of hospitalizations were associated with at least one ADE, accounting for an event rate of 52 ADEs per 100 admissions. The majority of errors that resulted in an ADE occurred in the medication ordering phase. The authors conclude that while there is a capacity to safely administer drugs using computers, more appropriate decision support at high-risk steps would improve current systems.