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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 28 Results
Hessels AJ, Guo J, Johnson CT, et al. Am J Infect Control. 2023;51:482-489.
Standard precautions, including hand hygiene and sharps safety, keep patients and staff safe, but adherence is suboptimal. An earlier systematic review shows an association between standard precaution compliance and overall safety climate. This study aimed to determine if adherence to standard precautions and safety climate were associated with healthcare associated infection (HAI) rates. Adherence rates were low (64%) and associated with HAI and healthcare worker needlesticks.
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.
Hessels AJ, Murray MT, Cohen B, et al. J Healthc Qual. 2018;40:384-391.
Researchers tested and validated a survey to measure safety culture in pediatric long-term care settings. The survey instrument was found to meet standards for reliability and concurrent validity, through association with overall safety ratings. They propose measuring and tracking safety culture using this survey in pediatric long-term-care facilities.
Cohen CC, Liu J, Cohen B, et al. Infect Control Hosp Epidemiol. 2018;39:509-515.
This matched case-control study examined costs and payments to hospitals related to hospital-acquired central line infections and catheter-associated urinary tract infections. Investigators found that hospitals could either experience financial penalty or gain depending on the particular payment structure for the patient. They suggest aligning payment structures more closely with safety goals.
Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Med Care. 2017;55:447-455.
The Centers for Medicare and Medicaid Services policy on nonpayment for certain hospital-acquired conditions serves as a strong incentive to prevent adverse events during hospitalization. This observational study examined Medicare's nonpayment policy for conditions such as health care–associated infections. As with prior studies, investigators determined that the incidence of hospital-acquired conditions declined following implementation of nonpayment. For certain conditions, such as catheter-associated urinary tract infections, hospitals with a larger proportion of Medicare patients had greater improvements. The authors note the variation in rates of hospital-acquired conditions and differing magnitude of improvement. They recommend further study to understand how to achieve similar successes in reducing hospital-acquired conditions.
Glance LG, Osler T, Li Y, et al. Med Care. 2016;54:608-15.
The weekend effect, in which patient outcomes are worse outside of usual business hours, is well-documented across multiple care settings. Analyzing administrative data, this study found a higher rate of complications in both urgent and elective surgery on the weekend compared to the weekdays. This finding emphasizes the need to develop and test strategies to enhance safety on evenings and weekends in acute care settings.
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.
Allegranzi B, Conway L, Larson EL, et al. Am J Infect Control. 2014;42:224-30.
The seemingly simple act of hand hygiene has proved to be a formidable obstacle in patient safety, as hand hygiene rates remain unacceptably low at many hospitals. In this survey of hospitals participating in the World Health Organization's hand hygiene program, greater overall infection control staffing appeared to be associated with a higher level of engagement in the project.
Glance LG, Osler T, Neuman MD. N Engl J Med. 2014;370:1379-1381.
Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.
Glance LG, Kellermann AL, Osler T, et al. JAMA Surg. 2014;149:439-45.
This retrospective cohort study applied the American College of Surgeons National Surgical Quality Improvement Program's risk calculator for post-operative complications to ascertain whether it would predict 30-day readmissions. As expected, patients who were predicted to have a high rate of complications were also more likely to be readmitted. The authors suggest that identifying patients at risk for both readmissions and complications prospectively may facilitate targeted intervention.
Glance LG, Dick AW, Osler T, et al. Arch Surg. 2011;146:1170-7.
The Leapfrog Group, a consortium of public and private employers who purchase health care for more than 30 million Americans, strives to improve patient safety through encouraging hospitals to implement the National Quality Forum's safe practices and 3 other key safety interventions (including computerized provider order entry). More than 1200 hospitals nationwide have joined the Leapfrog Group's effort to date. However, this analysis of hospital-level trauma outcomes found essentially no relationship between adoption of the Leapfrog interventions and outcomes for trauma patients. This study's results mirror the findings of a prior study that found no improvement in mortality at Leapfrog hospitals for a broad range of inpatient diagnoses.