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 - 13 of 13 Results
Huang SS, Septimus E, Kleinman K, et al. N Engl J Med. 2013;368:2255-2265.
Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This pragmatic, cluster-randomized trial to determine the most effective approach for reducing the rates of MRSA was implemented in 43 hospitals, including 74 ICUs and 74,256 patients. Compared to baseline, modeled hazard ratios for MRSA clinical isolates were 0.92 for those undergoing screening isolations, 0.75 for targeted decolonization, and 0.63 for universal decolonization. Universal decolonization resulted in significantly greater reduction in blood stream infections than the other two studied approaches for infection reduction.
Lee GM, Kleinman K, Soumerai SB, et al. N Engl J Med. 2012;367:1428-37.
In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.
Simon SR, Smith DH, Feldstein AC, et al. J Am Geriatr Soc. 2006;54:963-8.
This study demonstrated that replacing drug-specific alerts with age-specific ones sustained (but did not enhance) previously noted decreases in inappropriate prescribing with drug-specific alerts alone. Investigators conducted a cluster-randomized trial of seven practices that received age-specific alerts in addition to academic detailing with eight practices that received only the alerts. The academic detailing process involved an interactive educational program to assist with alternative and evidence-based medication choices. Findings suggested that clinical decision support can be effective using alert systems, but improvements in tools such as academic detailing are needed, as the process had no benefit in this study. Shifting to age-specific alerts did decrease the alert burden overall to providers. A past review discussed the issue of inappropriate prescribing in the elderly while other studies evaluated its prevalence in outpatient settings and elderly veterans.
Smith DH, Perrin N, Feldstein AC, et al. Arch Intern Med. 2006;166:1098-104.
This AHRQ–funded study discovered that the use of alerts within an electronic medical record system can reduce the number of unsafe medications prescribed in elderly outpatients. Investigators evaluated the impact of a clinical decision support system (CDSS) at the point of computerized provider order entry (CPOE), targeting two classes of contraindicated medications (long-acting benzodiazepines and tertiary amine tricyclic antidepressants). The authors discuss the rapid, significant, and persistent reductions in medication prescribing of these high-risk medications, suggesting the effectiveness of an alert system to curtail inappropriate prescribing. This study is a first to evaluate a computerized alert system in a large population-based primary care setting, although a past systematic review evaluated the effects of CDSS on practitioner performance and patient outcomes.
Davis RL, Kolczak M, Lewis E, et al. Epidemiology. 2005;16:336-41.
Given a lack of effective systems to detect adverse events with new vaccine administration, this study used existing data to compare event rates after changing to new rotavirus and diphtheria-pertussis-tetanus (DPT) vaccines. The surveillance system accurately captured adverse events, which supports the viability of similar systems in monitoring new vaccine safety.