Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 16 of 16 Results
Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.
The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.
Weaver SH, de Cordova PB, Ravichandran A, et al. J Nurs Care Qual. 2023;38:203-210.
Nurse work environment has been linked to perceived safety culture and job satisfaction. This cross-sectional survey of licensed practical nurses (LPNs) in New Jersey found lower job satisfaction and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working in other settings.
Pogorzelska-Maziarz M, Chastain AM, Mangal S, et al. J Am Med Dir Assoc. 2020;21:1782-1790.e4.
The COVID-19 pandemic has raised concerns about home healthcare, which is common among older and disabled patients managing chronic conditions. This qualitative study explored perceived successes and challenges with regards to infection prevention and control among home healthcare staff. Identified challenges included the unpredictability of the home environment, patient/family dynamics, the intermittent nature of home healthcare, and staffing issues. In the midst of the COVID-19 pandemic, home health leadership should consider these challenges as they prioritize infection prevention and control.
Needleman J, Liu J, Shang J, et al. BMJ Qual Saf. 2020;29:10-18.
Prior research has shown that nurse staffing is an important consideration with regard to patient safety. Lower nurse-to-patient ratios are associated with increased mortality and have prompted policies mandating particular nurse staffing ratios, especially in the intensive care unit. To address the criticism that previous studies have compared different institutions with higher nurse staffing to those with lower staffing levels and that there may be other reasons for observed differences in patient outcomes, this study evaluated the relationship between inpatient mortality and exposure to shifts with decreased registered nurse staffing, lower nursing support staffing, and increased patient turnover at three sites within a single academic medical center. Consistent with prior studies, researchers found an association between low nurse and nursing support staffing and increased patient mortality; there was no association between patient turnover and mortality. An accompanying editorial advocates for additional prospective research on interventions put in place to address nurse staffing.
Lake ET, de Cordova PB, Barton S, et al. Hosp Pediatr. 2017;7:378-384.
Missed nursing care is common and has been linked to adverse events. This survey found that more than half of pediatric intensive care unit nurses reported missing care during their prior shift. Higher patient loads and poor working environments were associated with more episodes of missed care, corroborating prior research.
Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. BMJ Qual Saf. 2015;24:637-44.
This qualitative study examined the effects of state and federal laws mandating public reporting for health care–associated infections. Participants believed that laws enhanced statewide collaboration and that public reporting led to greater investment in improvement work. The authors suggest that reporting requirements and definitions be uniform across states to reduce reporting burden.
Glance LG, Dick AW, Osler T, et al. Arch Surg. 2011;146:1170-7.
… hospitals to implement the National Quality Forum's safe practices and 3 other key safety interventions … 1200 hospitals nationwide have joined the Leapfrog Group's effort to date. However, this analysis of hospital-level … interventions and outcomes for trauma patients. This study's results mirror the findings of a prior study that found no …
Dunn-Navarra A-M, Cohen B, Stone PW, et al. J Nurs Care Qual. 2011;26:30-38.
This study found that organizations that prioritized teamwork—specifically by using morning huddles among nurses—reported higher rates of hand hygiene. Although system factors may play a role in suboptimal hand hygiene, some observers have argued for greater emphasis on individual responsibility in this area.
Stone PW, Mooney-Kane C, Larson EL, et al. Med Care. 2007;45:571-578.
This study examined the relationship between nurse staffing and hospital characteristics and specific patient safety measures, such as nosocomial infection rates and incidence of decubitus ulcers. Lower nurse-to-patient ratios and increased overtime both negatively impacted patient safety and in-hospital mortality, but hospital characteristics were not associated with safety measures. The study confirms and extends the findings of previous studies, which have demonstrated that lower nurse staffing and extended shifts are associated with self-reported errors and increased mortality.