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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 - 11 of 11 Results
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;51:1492-1501.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnosis (Berl). 2022;9:332-339.
Delayed diagnosis of infectious diseases can lead to serious patient harm. This survey of over 500 infectious disease clinicians revealed that diagnostic delay often involved diagnoses of infective endocarditis and epidural abscesses. Respondents identified several factors contributing to diagnostic delays including usual clinical presentations and the timing of infectious disease consultations.
Miller AC, Arakkal AT, Koeneman S, et al. BMJ Open. 2021;11:e045605.
Delayed diagnosis is a critical patient safety concern. This cohort study, consisting of 3,500 patients with tuberculosis (TB) over a 17-year period, found that more than three-quarters of patients experienced at least one missed opportunity for a diagnosis in the year before they were finally diagnosed with TB. The average duration of the diagnostic delay was nearly 32 days. Missed opportunities occurred most commonly in outpatient settings. A previous WebM&M commentary discusses patient harm resulting from a missed TB diagnosis.
Tartari E, Saris K, Kenters N, et al. PLoS One. 2020;15.
Presenteeism among healthcare workers can lead to burnout and healthcare-associated infections, but prior research has found that significant numbers of healthcare workers continue to work despite having influenza-like illness. This study surveyed 249 healthcare workers and 284 non-healthcare workers from 49 countries about their behaviors when experiencing influenza-like illness between October 2018 and January 2019. Overall, 59% of workers would continue to work when experiencing influenza-like illness, and the majority of healthcare workers (89.2-99.2%) and non-healthcare workers (80-96.5%) would continue to work with mild symptoms, such as a mild cough, fatigue or sinus cold.  Fewer non-healthcare workers (16.2%) than healthcare workers (26.9%) would continue working with fever alone.
Croft LD, Liquori M, Ladd J, et al. Infect Control Hosp Epidemiol. 2015;36:1268-74.
Contact precautions are essential to preventing the spread of health care–associated infections. Health care workers visit patients on contact precautions less often, and this has raised concerns about reduced vigilance increasing the risk of adverse events. This case-control study found that patients on contact precautions were actually less likely to experience noninfectious adverse events, allaying concerns about unintended consequences.
Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.
Hand hygiene adherence is a key target for improving patient safety. This guideline offers an overview of evidence-based strategies to monitor and promote hand hygiene, including resources developed by the Centers for Disease Control and Prevention and the World Health Organization's "5 moments" program. The authors provide detailed practice recommendations to increase hand hygiene compliance as a way to reduce health care–associated infections. The guideline is one of the 2014 infection control compendium updates published in the journal.
Schweizer ML, Cullen JJ, Perencevich E, et al. JAMA Surg. 2014;149:575-81.
This analysis found that excess hospital costs are significant for patients who experience surgical site infections in the Veterans Affairs system. The authors highlight how adhering to proven practices to reduce postoperative infections provides an opportunity to enhance safety while decreasing costs.
Ward MA, Schweizer ML, Polgreen PM, et al. Am J Infect Control. 2014;42:472-8.
This systematic review evaluated new technologies for assisting hand hygiene monitoring, including automated counting systems, video monitoring, and fully automated monitoring systems. Currently, there is very limited data about how accurate, effective, and valuable these strategies are in enhancing hand hygiene compliance.
Eber MR, Laxminarayan R, Perencevich E, et al. Arch Intern Med. 2010;170:347-53.
Health care–associated infections are common and the subject of wide-scale prevention programs, despite concerns about their use as a quality metric. This study used a national database to examine the clinical and economic costs attributed to the development of health care–associated sepsis and pneumonia. Analyzing nearly 600,000 cases, investigators found 2.3 million hospitalization days, $8.1 billion in in-hospital costs, and 48,000 preventable deaths attributed to health care–associated sepsis and pneumonia. They also reported at least 40% higher length of stay and costs in patients with these complications who underwent invasive procedures compared to those who did not. Despite limitations in utilizing administrative data to draw clinical details, the findings are notable. A related commentary [see link below] discusses reducing preventable harm in the context of this study's findings, calling for greater investments in the science of health care quality and safety.
McGregor JC, Weekes E, Forrest GN, et al. J Am Med Inform Assoc. 2006;13:378-84.
Clinical decision support systems (CDSS) are being increasingly incorporated into electronic medical record systems. In this quasi-randomized study conducted at an academic medical center, the CDSS combined laboratory and pharmacy data to provide guidance on appropriate antimicrobial therapy to the hospital's antibiotic management team. The antibiotic management team made significantly more interventions on patients randomized to the intervention arm, resulting in cost savings for the hospital. The CDSS was also more efficient, saving the team nearly 1 hour per day. A prior systematic review revealed that CDSS have been broadly effective at changing provider behavior, but their effect on patient outcomes remains to be determined.