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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 - 19 of 19 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.
Lane-Fall MB, Pascual JL, Peifer HG, et al. Ann Surg. 2020;271:484-493.
Handoffs represent a vulnerable time for patients in which inadequate communication between providers can contribute to adverse outcomes. Research has shown that the use of standardized handoff tools not only improves the process but also decreases errors. In this prospective cohort study, researchers implemented a handoff protocol designed to improve handoffs between the operating room and the intensive care unit (ICU) across two surgical ICUs at two hospitals. They examined omission of information across 13 topics contained in the handoff template before and after implementation. Standardization of the handoff process led to a decrease in omitted information and increased the length of time of the handoff. There was no impact on ICU mortality and length of stay. A past PSNet interview discussed implementation of a standardized handoff tool.
Sellers MM, Berger I, Myers JS, et al. J Surg Educ. 2018;75:e168-e177.
This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.
Lane-Fall MB, Pascual JL, Massa S, et al. Jt Comm J Qual Saf. 2018;44:514-525.
Standardizing handoffs has been shown to improve patient safety. The authors describe provider perspectives regarding handoffs from the operating room to intensive care unit as well as the development of a standardized OR-to-ICU handoff protocol.
Desai SV, Asch DA, Bellini LM, et al. New Engl J Med. 2018;378:1494-1508.
Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.
Delgado K, Shofer FS, Patel MS, et al. J Gen Intern Med. 2018;33:409-411.
To reduce opioid risk, the Centers for Disease Control and Prevention recommend that frontline providers minimize the number of opioid tablets they prescribe for acute pain. This pre–post study examined the effect of implementing a 10-tablet default prescription in the electronic medical record in two urban emergency departments. The intervention changed prescribing habits but did not reduce the already low overall number of tablets prescribed. Two PSNet perspectives explore the intersection of patient safety and the opioid epidemic.
Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-AP4.
Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.
Halpern S, Detsky AS. N Engl J Med. 2014;370:1086-1089.
Tracking changes in resident physician training since the landmark Libby Zion case in 1984, Drs. Halpern and Detsky review both the intended and unintended effects of ACGME work hour and supervision regulations. They describe the incremental loss of the traditional model of graded autonomy for residents and point out the lack of evidence in support of this new approach. For instance, a recent study showed that having in-house critical care attendings overnight did not improve outcomes compared with having in-house residents with as-needed telephone access to their supervisors. The authors call for the ACGME and other training program regulators to promote evaluations of various models of graded autonomy, rather than set "one rigid standard on the basis of conjecture alone." Studies should examine outcomes of future patients cared for by physicians that were exposed to different training environments, as well as shorter-term evaluations of residents' current clinical competence. A prior AHRQ WebM&M interview with Dr. Thomas Nasca, head of the ACGME, discussed duty hours and the balance of autonomy with oversight.
Buser GL, Fisher BT, Shea JA, et al. Am J Infect Control. 2013;41:492-6.
Engaging patients has been an area of emphasis for the safety movement, spurred by data demonstrating that patients often feel uncomfortable asking questions of their clinicians. This survey found that most parents of hospitalized children were interested in participating in hand hygiene efforts, but one-third would feel uncomfortable reminding health care workers to wash their hands. This reluctance has been documented in prior studies and may arise from patients' fear of endangering their relationship with the care team. In order to address these barriers, the Agency for Healthcare Research and Quality recently published a guide to patient and family engagement in quality and safety programs, which was designed with input from clinicians and patients.
Shea JA, Willett LL, Borman KR, et al. Acad Med. 2012;87:895-903.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.