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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 - 17 of 17 Results
Emond YEJJM, Calsbeek H, Peters YAS, et al. Br J Anaesth. 2022;128:562-573.
A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.
van Gelderen SC, Zegers M, Robben PB, et al. BMC Health Serv Res. 2018;18:798.
Auditing for compliance with safety practices is performed frequently in the health care setting, both for learning and feedback as well as for regulatory purposes. In this survey study involving boards of directors and hospital leaders from 89 acute care hospitals in the Netherlands, researchers sought to identify factors for effective auditing and provide suggestions for how hospital boards can use such auditing practices to inform governance.
van Dusseldorp L, de Waal GH-, Hamers H, et al. Jt Comm J Qual Patient Saf. 2016;42:545-554, AP1-AP3.
In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.
Zegers M, Hesselink G, Geense W, et al. BMJ Open. 2016;6:e012555.
This review examined the evidence base for reducing adverse events in hospitals. Investigators found sufficient evidence to support implementation of certain types of interventions, such as rapid response teams to reduce cardiac arrest and mortality rates, bundles and checklists to mitigate hospital-acquired infections, and pharmacist interventions to decrease adverse drug events. However, the overall evidence base for many of the patient safety interventions used by hospitals is weak.
Hanskamp-Sebregts M, Zegers M, Vincent CA, et al. BMJ Open. 2016;6:e011078.
Detection of safety hazards remains a challenge. This systematic review examined record review as a way to identify adverse events. Consistency of event identification was adequate, but data are lacking regarding validity of medical record review compared to other safety assessment methods, such as direct observation of patient care. The authors recommend formal validation of record review as a method to detect adverse events.
Hesselink G, Berben S, Beune T, et al. BMJ Open. 2016;6:e009837.
The growing focus on enhancing health care safety has placed new demands on hospital leadership to implement improvement initiatives. Examining governance of patient safety in the emergency department, this systematic review found that robust tools for monitoring patient safety and reporting errors are lacking.
van Sluisveld N, Hesselink G, van der Hoeven JG, et al. Intensive Care Med. 2015;41:589-604.
This systematic review revealed that limited evidence exists exploring handoffs from intensive care units to general wards, and most of the studies identified were of low quality. Two promising interventions include employing liaison nurses working across multiple settings and structured communication, which has been shown to improve handoffs. The authors advocate for these interventions to be tested widely in rigorous studies to determine their effectiveness.
Weenink JW, Westert GP, Schoonhoven L, et al. BMJ Qual Saf. 2015;24:56-64.
In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.
Borghans I, Hekkert KD, Ouden L den, et al. BMJ Open. 2014;4:e004773.
Currently, no reliable method exists for comparing patient safety between hospitals. The hospital standardized mortality ratio, which compares observed with expected mortality for specific diagnoses, is widely used but has been decried as inaccurate and subject to gaming. Similarly, deaths in patients with low-mortality diagnoses are also used to identify safety problems, but these events are rare and unpredictable in many cases. Adverse events are known to result in longer hospitalizations. This Dutch study used a national database to examine whether unexpectedly long length of stay could be used as an indicator of the safety and quality of care. This preliminary study found that rates of unexpectedly long hospital stays varied widely between hospitals and were correlated with other quality measures. Although much more work is required to validate this measure, it may fill a need as a measure of patient safety that allows comparisons between hospitals.
Hesselink G, Vernooij-Dassen M, Pijnenborg L, et al. Med Care. 2013;51:90-8.
Focus groups of patients, hospital physicians, outpatient physicians, and nurses revealed many aspects of organizational culture that impede progress in enhancing care transitions. A recent systematic review identified promising strategies for improving continuity of care at discharge.
Göbel B, Zwart DLM, Hesselink G, et al. BMJ Qual Saf. 2012;21 Suppl 1:i106-13.
Although seminal studies have documented persistent problems in care transitions, including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems remains incomplete. This Dutch study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews with patients, nurses, hospital physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective and ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, implying the need for both technological solutions and increased personal contact between hospital-based and outpatient clinicians. This study is part of a special theme issue of BMJ Quality and Safety dedicated to the issue of care transitions.