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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 - 11 of 11 Results
Brooks Carthon M, Brom H, McHugh MD, et al. Med Care. 2021;59:169-176.
Prior research has shown that lower nurse-to-patient ratios are associated with increased patient mortality. This cross-sectional analysis using multiple data sources from four states assessed the relationship between nurse staffing and survival disparities after in-hospital cardiac arrest. Results indicate that disparities in survival between Black and white patients may be linked to medical-surgical nurse staffing levels, and that the benefit of being treated at a hospital with higher staffing ratios may be especially pronounced for Black patients.
Wolfe H, Zebuhr C, Topjian AA, et al. Crit Care Med. 2014;42:1688-95.
This single-center prospective study found that providing interdisciplinary post-event debriefs with quantitative feedback on chest compression depth, rate, and other indicators of high-quality cardiopulmonary resuscitation significantly improved cardiac arrest outcomes in a pediatric intensive care unit.
Lovig KO, Horwitz LI, Lipska K, et al. Jt Comm J Qual Patient Saf. 2012;38:403-407.
A retrospective chart review revealed that approximately 1 in 8 patients with diabetes was discharged without any antihyperglycemic therapy following acute myocardial infarction. Almost 90% of these omissions lacked justification, suggesting widespread errors in medication reconciliation.
Salisbury AC, Reid KJ, Alexander KP, et al. Arch Intern Med. 2011;171:1646-53.
This study discovered that blood loss from greater use of phlebotomy was independently associated with hospital-acquired anemia. An accompanying editorial [see additional link below] discusses this hazard of hospitalization in the context of more than just never events.
Chan PS, Jain R, Nallmothu BK, et al. Arch Intern Med. 2010;170:18-26.
… Most hospitals maintain some form of RRS, due in part to a 2008 National Patient Safety Goal that required hospitals to maintain a dedicated system for urgent assistance for clinically … quality of many RRS studies. RRS have proven to be a very popular intervention among nursing staff , and this …
Chan PS, Khalid A, Longmore LS, et al. JAMA. 2008;300:2506-13.
A rapid response team consisting of ICU nurses and respiratory therapists with physician backup failed to affect mortality or cardiopulmonary arrest rates at a tertiary care community hospital. While several studies and reviews have attempted to address the effectiveness of rapid response systems, this study's conclusions are strengthened by sophisticated statistical analysis, as well as the finding that the rapid response team was not underutilized (a criticism of prior negative trials). These findings are contrary to those reported in a recent trial conducted in a children's hospital. Despite already being widely implemented, rapid response systems are likely to remain controversial.
Chan PS, Krumholz HM, Nichol G, et al. N Engl J Med. 2008;358:9-17.
… … N Engl J Med … Delays in treatment are common and pose a significant threat to patient safety. This study evaluated nearly 7000 patients who experienced a cardiac arrest due to “shockable” rhythms, and discovered … similar delays around resuscitative efforts. … Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart …