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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 40 Results
Mahmoud HA, Thavorn K, Mulpuru S, et al. BMJ Open Qual. 2023;12:e002134.
Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.
Sauro KM, Soo A, de Grood C, et al. Crit Care Med. 2020;48:946-953.
Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. JAMA Netw Open. 2019;2:e1910756.
Medication reconciliation aims to prevent adverse events after hospital discharge. In this cluster randomized trial, researchers evaluated the impact of an electronic medication reconciliation intervention involving automatic integration of community drug data and found that this process reduced medication discrepancies but did not reduce adverse events. 
McIsaac DI, Hamilton GM, Abdulla K, et al. BMJ Qual Saf. 2020;29:209-216.
The AHRQ Patient Safety Indicators (PSIs), which are used to screen administrative data for patient safety events, have been revised in response to the new ICD-10 coding system. This study sought to validate the accuracy of ICD-10-based PSIs for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program reference standard. Although the PSIs had relatively high negative predictive value (meaning that the absence of a PSI meant that the patient likely had not experienced an adverse event), the overall accuracy was not sufficient to warrant using PSIs as the sole strategy to detect adverse events.
Forster AJ, Hamilton S, Hayes T, et al. Healthc Manage Forum. 2019;32:266-271.
The just culture paradigm shifts the response to error from a retrospective focus on blame to the system that contributed to the incident. This commentary describes one hospital's strategic and operational approach to just culture development and the results of the initiative.
Forster AJ, Huang A, Lee TC, et al. BMJ Qual Saf. 2020;29.
This prospective study used a trigger tool approach to identify potential adverse events among hospitalized patients in real time. Researchers found widely varying adverse rates among the five hospitals and concluded that event detection among the trigger event reviewers was responsible for some of the variation in observed events. These results underscore the challenge of accurate adverse event surveillance.
Santana MJ, Holroyd-Leduc J, Southern DA, et al. BMJ Qual Saf. 2017;26:993-1003.
Preventing adverse events after hospital discharge remains a top patient safety priority. In this randomized controlled trial, researchers found that the implementation of an electronic discharge communication tool did not significantly reduce death or readmission within 90 days of discharge.
Bhatt M, Johnson DW, Chan J, et al. JAMA Pediatr. 2017;171:957-964.
Procedural sedation is more commonly used among pediatric patients compared to adult patients. In this prospective study across six emergency departments, researchers found that the occurrence of serious adverse events among children receiving sedation varied depending on the type of medication used.
Kobewka DM, van Walraven C, Turnbull J, et al. BMJ Qual Saf. 2017;26:141-149.
Inpatient mortality represents a key outcome measure in health care quality and safety. This study described the implementation of an institution-wide mortality review process, which identified significant opportunities to improve care, especially around discussing goals of care and delays in diagnosis.
Southern DA, Burnand B, Droesler SE, et al. Med Care. 2017;55:252-260.
AHRQ Patient Safety Indicators (PSIs) have been utilized to identify safety problems and suboptimal care quality in acute care settings using ICD-9 codes in administrative discharge data. Despite limitations in the accuracy of PSIs, they have been widely employed as a quality metric. The implementation of ICD-10 and diagnosis timing codes necessitate development of a new set of PSIs. This consensus and validation study used a Delphi panel process to determine ICD-10 codes associated with safety and quality concerns. Experts grouped the 640 identified diagnostic codes into 18 PSI categories. Application of these novel PSIs in over 10 years of hospital discharge data uncovered safety problems in 5% of hospitalizations. The authors recommend that these proposed PSIs should be further validated using record review or prospective case review.
Okoniewska B, Santana MJ, Holroyd-Leduc J, et al. BMC Health Serv Res. 2016;16:357.
Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.
Hewitt T, Chreim S, Forster AJ. J Eval Clin Pract. 2016;22:267-74.
… Journal of evaluation in clinical practice … J Eval Clin Pract … Manual double checking of high-risk …
Calder LA, Pozgay A, Riff S, et al. BMJ Qual Saf. 2015;24:142-148.
This observational study examined all return emergency department visits within 7 days of an initial visit to determine if the second visit was caused by an adverse event. An adverse event was present in 12% of return visits that occurred within 72 hours of the initial visit. The authors suggest that this utilization pattern may be a promising trigger tool to identify adverse events.