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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
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
Kravet SJ, Bhatnagar M, Dwyer M, et al. J Patient Saf. 2019;15:e98-e101.
J Patient Saf … Few models for systematically targeting … to safety improvements in other large health systems.    … Kravet S, Bhatnagar M, Dwyer M, Kjaer K, Evanko J, Singh H. Prioritizing Patient Safety Efforts in Office …
Zuccotti G, Samal L, Maloney FL, et al. Ann Intern Med. 2018;168:820-821.
Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.
Dykes PC, Rozenblum R, Dalal A, et al. Crit Care Med. 2017;45.
Establishing a strong safety culture may lead to a reduction in adverse events. Many health care institutions are focused on improving multiple aspects of culture including teamwork, communication, and patient engagement to mitigate harm. In this prospective study, researchers sought to understand the impact of a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit. They included 1030 admissions in the baseline period and 1075 in the intervention period. The rate of adverse events decreased by almost 30%, from 59.0 per 1000 patient days in the baseline period to 41.9 per 1000 patient days during the intervention period. Patient and care partner satisfaction improved as well. A past PSNet perspective discussed the relationship between patient engagement and patient safety.
Kravet SJ, Bailey J, Demski R, et al. Acad Med. 2016;91:962-6.
Oversight of safety improvement programs in the ambulatory setting is challenging due to variations in outpatient processes and complexity of care. This commentary describes an ambulatory accountability structure that involves a quality advisory council, led by a physician and a nurse, which established accountability, standards, and best practices across a large health care system to engage frontline staff in developing and sustaining improvements.
Desai SV, Feldman LS, Brown L, et al. JAMA Intern Med. 2013;173.
The Accreditation Council for Graduate Medical Education (ACGME) has progressively restricted resident physicians' duty hours since 2003, with the goal of improving patient safety and resident quality of life. Despite evidence that the 2003 regulations had no significant impact on patient outcomes and may have adversely affected resident education, further regulations implemented in 2011 placed new restrictions on the duty hours of first-year trainees. This randomized controlled trial, in which two 2011-compliant internal medicine resident schedules were compared with the existing schedule (which was compliant with the 2003 regulations), represents one of the first assessments of the new regulations. The investigators found that although residents slept more under the new schedules, the number of handoffs increased dramatically, residents' attendance at teaching conferences decreased, and both residents and nurses perceived that the quality of patient care worsened. An accompanying editorial calls for the ACGME to eliminate shift length restrictions and instead focus on reducing overall resident workload.
Michtalik HJ, Yeh H-C, Pronovost P, et al. JAMA Intern Med. 2013;173:375-7.
Excessive workloads for nurses and resident physicians have previously been associated with adverse events. This survey found that 40% of attending hospitalists felt their inpatient census exceeded safe levels at least monthly and that busy workloads may adversely impact their patient care.
McGuire MJ, Noronha G, Samal L, et al. J Gen Intern Med. 2013;28:184-92.
Electronic medical records (EMRs) are generally perceived to improve patient safety, and prior reviews have found that EMR implementation is associated with improvement in some measures of safety and quality. This study of EMR implementation in a large primary care medical group found a positive association between implementation of a new EMR and safety culture, with sustained improvement in Safety Attitudes Questionnaire scores over a 3-year period following implementation. Interestingly, the perceived improvement in safety culture was smallest in the first year of use of the new EMR; a prior study found that 1 year of experience was necessary before primary care physicians felt a new EMR improved safety and quality.