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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 26 Results
Fleisher LA, Schreiber M, Cardo D, et al. N Engl J Med. 2022;386:609-611.
The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.
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.
Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019;130:1039-1048.
Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.
Lane-Fall MB, Pascual JL, Peifer HG, et al. Ann Surg. 2020;271:484-493.
… Ann Surg … Handoffs represent a vulnerable time for patients in which inadequate … In this prospective cohort study, researchers implemented a handoff protocol designed to improve handoffs between the … Standardization of the handoff process led to a decrease in omitted information and increased the length of …
Diraviam SP, Sullivan P, Sestito JA, et al. Jt Comm J Qual Patient Saf. 2018;44:605-612.
Physician engagement in quality and safety improvement contributes to the sustainability of initiatives. This commentary describes how an academic health system engaged physicians in leading improvement efforts. The project encouraged use of local malpractice claims to design interventions and motivate physician involvement in quality improvement work.
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.
Rhee C, Dantes RB, Epstein L, et al. JAMA. 2017;318:1241-1249.
Early identification of sepsis is essential for initiating appropriate treatment and preventing mortality. In this retrospective study, researchers used clinical data to estimate the incidence of sepsis over time at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis remained stable during this time. Although inpatient mortality due to sepsis declined somewhat, there was no change in the combined outcome of death or discharge to hospice. 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 to hospice. The authors conclude that analysis of clinical data may provide a better understanding of sepsis trends. The accompanying editorial highlights challenges associated with measuring the sepsis incidence and mortality.
Mohan D, Schell J, Angus DC. JAMA. 2016;316:1867-1868.
Heuristics enable experts to build off their experience to arrive at decisions rapidly. However, heuristics can contribute to error and are often discussed in the context of diagnostic missteps. This commentary argues that gaming strategies, which have been proven to improve surgical technique, can hone clinical decision making by helping providers switch from immediate to deliberate mode of reasoning.
Network WG for the CHECKLIST-ICUI and the BR in IC, Cavalcanti AB, Bozza FA, et al. JAMA. 2016;315:1480-90.
… clinical trial studied the effect of introducing a daily checklist, goal setting, and clinician prompting in … The intervention group showed some improvements in a few process measures, such as use of low tidal volumes, …
WebM&M Case September 1, 2015
… man with no significant past medical history sustained a traumatic brain injury after a motor vehicle collision … … The Commentary … by LauraEllen Ashcraft, MSW, and Jeremy M. Kahn, MD, MS … The case demonstrates the many difficulties … 2014;33:1345-1352. [go to PubMed] 8. Kahn JM, Le T, Angus DC, et al; ProVent Study Group Investigators. The …
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.