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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 27 Results
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Hawkins RB, Nallamothu BK. BMJ Qual Saf. 2023;32:181-184.
A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
… despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with … rates as much as earlier studies have reported. … Girotra S,  Jones PG, Peberdy MA, et al. Association of rapid response teams with hospital mortality …
Eldridge N, Wang Y, Metersky M, et al. JAMA. 2022;328:173-183.
… … Improving patient safety in hospitals is a longstanding national priority. Using longitudinal Medicare data from 2010 … for four common conditions – acute myocardial infarction, heart failure, pneumonia, and surgical procedures. … Eldridge N,  Wang Y, Metersky M, et al. Trends in adverse event rates in hospitalized …
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
Dharmarajan K, Wang Y, Lin Z, et al. JAMA. 2017;318:270-278.
… fee-for-service patients admitted to hospitals with heart failure , acute myocardial infarction, or pneumonia … each condition at each hospital. They then examined the association between hospitals' monthly trends in 30-day … do not lead to increased mortality. A previous WebM&M commentary discussed an incident involving a patient …
Wang Y, Eldridge N, Metersky ML, et al. J Am Heart Assoc. 2016;5.
Readmissions are subject to nonpayment by Medicare, but their use as a marker of quality is controversial. Experts have also raised concerns about the use of in-hospital mortality as a quality measure. Utilizing data from the AHRQ Medicare Patient Safety Monitoring System and the Centers for Medicare and Medicaid Services, this secondary analysis examined the link between rates of adverse events and rates of readmissions and 30-day mortality for patients treated for acute myocardial infarction in 793 hospitals. Investigators found that hospitals with a greater aggregate rate of adverse events also had higher readmission and mortality rates among patients with acute myocardial infarctions. Although readmission rates and mortality ratios have been criticized as inaccurate measures of the quality of care, the authors conclude that readmission and mortality rates do in fact reflect the quality of care in hospitals. A PSNet interview discussed the intersection of readmissions and quality.
Chen SI, Fox ER, Hall K, et al. Health Aff (Millwood). 2016;35:798-804.
Drug shortages have been a persistent problem for several years and have been shown to affect patient safety. The Food and Drug Administration Safety and Innovation Act of 2012 was intended to address these shortages. This analysis found that while shortages have decreased since the act was passed, problems with drug supply for acute care facilities remain.
Kachalia A, Mello MM, Nallamothu BK, et al. Circulation. 2016;133:661-71.
This review explores policy and legal approaches to addressing care delivery problems, including strategies that focus on transparency, reimbursement, professional regulation, and tort reform. The authors suggest cardiologists are well-positioned as leaders in adopting these approaches because the conditions they treat are highly visible, common, and expensive.
Metersky M, Eldridge N, Wang Y, et al. J Hosp Med. 2016;11:276-82.
Anticoagulation medications are often associated with adverse drug events. This study found that less-than-daily monitoring of anticoagulation in hospitalized patients is associated with more frequent out-of-range values, suggesting that daily monitoring is safer.
Wang Y, Eldridge N, Metersky M, et al. N Engl J Med. 2014;370:341-51.
The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.
Bradley EH, Curry LA, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-14.
Patients hospitalized for acute myocardial infarction (AMI) or congestive heart failure (CHF) are more likely to require hospital readmission within 30 days of discharge. Intensive efforts are underway to reduce readmissions in these patients, spurred by federal policies that penalize hospitals with excess readmission rates. However, this survey of nearly 600 hospitals found widely varying implementation of specific strategies to decrease readmissions in these patients, despite nearly all hospitals having declared reducing AMI and CHF readmissions to be a priority. The authors acknowledge that a lack of evidence supporting strategies to reduce readmissions, as well as variability in the underlying causes of readmissions between hospitals, may have influenced which interventions were implemented at different hospitals.
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.
… Archives of internal medicine … Arch Intern Med … Rapid response systems are one of the most widely deployed patient safety interventions in … hospitals maintain some form of RRS, due in part to a 2008 National Patient Safety Goal that required hospitals to …
Tsai TT, Maddox TM, Roe MT, et al. JAMA. 2009;302:2458-64.
… as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing … have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications. …