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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 - 10 of 10 Results
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  
Auerbach AD, Kripalani S, Vasilevskis EE, et al. JAMA Intern Med. 2016;176:484-93.
Preventing readmissions is a cornerstone of patient safety efforts. However, one concern about nonpayment for readmissions is that many may not be preventable. To determine whether they were preventable, this observational study investigated readmissions through patient and physician surveys along with chart review. Researchers determined that only one quarter of readmissions were preventable. Factors associated with potential preventability were premature hospital discharge, insufficient communication with outpatient providers, failure to discuss care goals, and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple interventions will be needed to avert readmissions, and such efforts will have limited impact since most readmissions are not preventable.
Lagu T, Goff SL, Craft B, et al. J Hosp Med. 2016;11:52-5.
Researchers in this study reviewed patient feedback posted on a hospital's Facebook page to determine whether social media may be a helpful mechanism for identifying patient safety and quality improvement issues. In this small sample of 37 respondents over a 3-week period, insights from social media comments did not seem to add much to the feedback already collected by more traditional methods, such as patient satisfaction surveys.
Perspective on Safety May 1, 2013
… patients in US hospitals each year depends on it. … Peter K. Lindenauer MD, MSc … Director, Center for Quality of Care …
This piece discusses efforts to promote the business case for safety and quality in health care.
Harvard internist Dr. Jha is a national leader in policy issues related to safety and quality.
Rothberg MB, Pekow PS, Liu F, et al. J Hosp Med. 2008;3:91-102.
This retrospective cohort study discovered that nearly 50% of patients received a potentially inappropriate medication (PIM) during hospitalization. Patients with myocardial infarction or heart failure were most likely to receive a PIM whereas men, those in managed care plans, and patients older than 85 were least likely.
Lindenauer PK, Rothberg MB, Pekow PS, et al. New Engl J Med. 2007;357:2589-2600.
Hospitalists are the fastest-growing medical specialty in the US, but their effect on quality of inpatient care has not been comprehensively assessed. This large observational study compared outcomes of patients cared for by hospitalists, general internists, and primary care physicians. Inpatient mortality and readmission rates were similar across all three groups of patients, and while hospitalists' patients had a slightly shorter length of stay, costs of care were also similar across groups. The study also did not find a relationship between case volume and outcomes. 
Lindenauer PK, Ling D, Pekow PS, et al. J Hosp Med. 2006;1:221-30.
The pace of implementation of computerized physician order entry (CPOE) in U.S. hospitals has remained slow, and most prior research has taken place at academic hospitals where residents place most orders. This study measured physician-specific CPOE usage at two community hospitals where both CPOE and standard written order entry were allowed and surveyed attending physicians at those hospitals about their perceptions and usage of CPOE. The study revealed that nearly one-third of physicians still hand-wrote most of their orders, even if they had prior exposure to CPOE or used computers for personal activities. The authors discuss potential strategies to encourage "low users" to embrace CPOE.
Rothberg MB, Abraham I, Lindenauer PK, et al. Med Care. 2005;43:785-91.
This cost-effectiveness analysis examined a variety of patient-to-nurse ratios in general medical and surgical settings. Investigators determined that an 8:1 ratio created the least expense but was also associated with the highest mortality rates. While decreasing the ratio incrementally to 4:1 improved mortality rates, it became more costly and progressively less cost-effective, but not outside of acceptable ranges. The authors conclude that defined nurse staffing ratios provide an opportunity for a cost-effective patient safety intervention comparable to other interventions of similar scope.
WebM&M Case October 1, 2004
… the user and prohibit such actions from being completed. … Peter Lindenauer, MD, MSc … Division of Healthcare Quality Baystate … site ]. 6. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to …