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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 39 Results
Karlic KJ, Valley TS, Cagino LM, et al. Am J Med Qual. 2023;38:117-121.
Because patients discharged from the intensive care unit (ICU) are at increased risk of readmission and post-ICU adverse events, some hospitals have opened post-ICU clinics. This article describes safety threats identified by post-ICU clinic staff. Medication errors and inadequate medical follow-up made up nearly half of identified safety threats. More than two-thirds were preventable or ameliorable.
O’Hare AM, Vig EK, Iwashyna TJ, et al. JAMA Netw Open. 2022;5:e2240332.
Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.
Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.
Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174:927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Sjoding MW, Dickson RP, Iwashyna TJ, et al. N Engl J Med. 2020;383:2477-2478.
Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.
Barbash IJ, Kahn JM. J Crit Care. 2019;54:88-93.
J Crit Care … J Crit Care … Hospital policies should help guide the quality … hospitals and widen health disparities. … Barbash IJ, Kahn JM. Sepsis quality in safety-net hospitals: An analysis of Medicare's SEP-1 performance measure.  J Crit Care . 2019;54:88-93. doi:10.1016/j.jcrc.2019.08.009 …
Harbaugh CM, Lee JS, Chua K-P, et al. JAMA Surg. 2019;154:e185838.
This retrospective cohort study found that adolescent patients who received opioids for surgical and dental procedures were more likely to develop persistent opioid use if they had family members with long-term opioid use. The study team recommends preoperative screening for long-term opioid use in family members as part of prescribing decision-making for adolescent patients.
Hallam BD, Kuza CC, Rak K, et al. BMJ Qual Saf. 2018;27:836-843.
This qualitative study employed direct observation of intensive care unit rounds and interviews with clinicians to delineate barriers and facilitators of rounding checklists. Researchers found that checklist use is related to perceived relevance and impact on work efficiency as well as quality and safety. They suggest that better integration of checklists into rounding workflow could improve their implementation.
Desai SV, Asch DA, Bellini LM, et al. New Engl J Med. 2018;378:1494-1508.
… New Engl J Med … Duty hour reform for trainees was undertaken to … to those working within standard duty hours. As in a prior study of surgical training, program directors of … effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME …
Rhee C, Dantes RB, Epstein L, et al. JAMA. 2017;318:1241-1249.
… at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis … In contrast, analysis of claims-based data suggests a significant increase in the incidence of sepsis over time as well as a marked decrease in sepsis mortality and death or discharge …
WebM&M Case September 1, 2015
… man with no significant past medical history sustained a traumatic brain injury after a motor vehicle collision … AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468. [go to PubMed] 2. CARE Item Set … 2015;372:1927-1936. [go to PubMed] 7. Ridgely SM, de Vries D, Bozic KJ, Hussey PS. Bundled payment fails to gain a
Liu V, Escobar GJ, Greene JD, et al. JAMA. 2014;312:90-2.
This study used national databases to demonstrate that sepsis accounted for more than one-third of all in-hospital deaths among adults. Sepsis care has been the focus of intense quality improvement efforts over the past few years, and these efforts are justified by the high prevalence of this disease.
Volpp KG, Small DS, Romano PS, et al. J Gen Intern Med. 2013;28:1048-55.
Although the 2003 duty hour regulations for resident physicians were intended as a patient safety intervention, concerns were raised that the rules might actually result in patient harm by increasing handoffs. These concerns were allayed by prior studies that found no increase in mortality at teaching hospitals after duty hours were restricted. This follow-up study tracked 5-year outcomes among Medicare patients and found no increase in mortality rates at teaching hospitals compared with less teaching-intensive hospitals. While it now appears clear that the 2003 duty hour limits had little impact on either safety outcomes or clinical outcomes, the effect of further regulations implemented in 2011 remains to be seen.
Volpp KG, Shea JA, Small DS, et al. JAMA. 2012;308:2208-17.
Seminal studies and widely publicized cases have linked fatigue among trainee physicians with medical errors. In response, the Accreditation Council for Graduate Medical Education (ACGME) has progressively limited duty hours for residents over the past decade. While first-year trainees now may work no more than 16 consecutive hours, upper-level residents may still be on duty for 24 consecutive hours; the ACGME strongly recommends protected sleep time during such extended shifts. Conducted at a single internal medicine residency's two teaching hospitals, this randomized controlled trial found that residents assigned to receive protected sleep time did sleep more and were less fatigued—by subjective and objective measures—compared with residents who had no protected sleep opportunity. However, increased sleep did not translate into improved patient-level clinical outcomes, and extra staffing was required (at one of the two hospitals) to implement the intervention. As prior studies of earlier regulations also did not find improvement in clinical outcomes after duty hour reduction, the relationship between physician work hours and patient safety remains complex and poorly defined.
Navathe AS, Silber JH, Small DS, et al. Health Serv Res. 2013;48:476-98.
The 2011 Accreditation Council for Graduate Medical Education's (ACGME) resident duty hour restrictions have placed additional financial pressures on teaching hospitals. However, this study found that patient outcomes did not vary by hospital financial status following the prior ACGME duty hour limits in 2003.