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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 - 14 of 14 Results
Fink DA, Kilday D, Cao Z, et al. JAMA Netw Open. 2023;6:e2317641.
Ensuring all pregnant individuals receive safe maternal care is a national health priority. Using a large national database, this study describes trends in delivery-related severe maternal morbidity (SMM) and mortality in the United States. Maternal mortality decreased for all racial, ethnic, and age groups, while SMM increased for all groups, particularly racial and ethnic minoritized groups. Patients with COVID-19 had a significantly increased risk of death. PSNet features a curated library of maternal safety resources.
Fink BC, Uyttebrouck O, Larson RS. J Law Med Ethics. 2020;48:249-258.
The overprescribing of opiates is a known contributor to the opioid epidemic. This essay describes governmental action taken to adjust prescribing patterns, their effect, and strategies to increase the impact of these actions on opioid misuse and patient harm.
Dieplinger B, Egger M, Jezek C, et al. Am J Infect Control. 2020;48:386-390.
This observational study enrolled 2,576 women undergoing cesarean delivery at a single tertiary care hospital over a five-year period to evaluate the impact of an evidence-based bundle on surgical site infections. The comprehensive and multidisciplinary bundle included preoperative, intraoperative and postoperative actions. Implementation of the bundle resulted in a 60% reduction in the risk of surgical site infections, from 1.5% in the preintervention period to 0.56% after implementation.
Brezis M, Orkin-Bedolach Y, Fink D, et al. J Patient Saf. 2019;15:296-298.
Investigators presented medical students and physicians at three university medical centers with a clinical vignette to explore levels of confidence, accuracy, and comfort with admitting a mistake. Physicians had higher levels of confidence but less accuracy compared to medical students, and they were less willing to admit making an error. There was a weak association between overconfidence and discomfort with error disclosure.
Croft LD, Liquori M, Ladd J, et al. Infect Control Hosp Epidemiol. 2015;36:1268-74.
Contact precautions are essential to preventing the spread of health care–associated infections. Health care workers visit patients on contact precautions less often, and this has raised concerns about reduced vigilance increasing the risk of adverse events. This case-control study found that patients on contact precautions were actually less likely to experience noninfectious adverse events, allaying concerns about unintended consequences.
Croft LD, Harris AD, Pineles L, et al. Clin Infect Dis. 2015;61:545-53.
Glove and gown precautions are a cornerstone of infection control in hospital settings. Prior studies have shown that patients under infection control precautions are more likely to experience adverse events, presumably due to fewer observations by providers, for whom entering isolation rooms requires time and effort. This cluster randomized trial examined whether patients in intensive care units that employed universal glove and gown precautions (contact precautions on all patients) experienced more adverse events (as measured by the IHI Global Trigger Tool) than those in units with standard precautions (contact precautions only for patients known to be infected or colonized with certain organisms). Rates of adverse events were similar in units with universal gown and glove precautions and those with standard precautions. These results suggest that universal glove and gown precautions are safe enough to test as an infection control strategy, though their overall efficacy remains uncertain.
Birkmeyer JD, Finks JF, O'Reilly A, et al. N Engl J Med. 2013;369:1434-1442.
Prior research has shown that surgical outcomes differ greatly by surgeon and facility, and a national program focuses on reducing this variability. This groundbreaking study has profound implications for improving the safety of surgery. At least 10 independent surgeon-reviewers examined video-recordings of 20 bariatric surgeons performing a laparoscopic procedure and rated the surgeons' skills, with a higher score representing better technical skills. Surgeons rated in the lowest quartile of surgical skill had more surgical complications, longer surgical times, and higher mortality within 30 days of the surgery than those in the highest quartile of surgical skill. This study is the first to link practicing surgeons' directly observed technical skills to surgical safety outcomes. It underscores the need to broaden surgical improvement efforts beyond the use of systems approaches, such as teamwork and surgical checklists, and suggests incorporating technical skills assessment into programs that aim to either measure or enhance the quality and safety of care.
Birkmeyer NJO, Finks JF, Greenberg CK, et al. Ann Surg. 2013;257:260-5.
Bariatric surgery—elective surgical procedures designed to induce weight loss in patients with obesity—is becoming increasingly common in the United States. This study, conducted in 22 hospitals in Michigan, examined whether safety culture was associated with the risk of serious complications in patients undergoing bariatric surgery. The authors surveyed operating room nurses and surgeons (using a modified version of the AHRQ Hospital Survey on Patient Safety Culture) and found that hospitals considered to have stronger safety culture also had significantly fewer serious complications among bariatric surgery patients. Hospitals in which nurses felt teamwork and coordination were poor tended to have the highest complication rates, a finding documented in prior studies of surgical safety culture. This study adds to a growing body of literature that links safety culture to clinical outcomes.
Seliger SL, Zhan M, Hsu VD, et al. J Am Soc Nephrol. 2008;19:2414-9.
This study found that patients with chronic kidney disease experienced more hospital adverse events as measured by AHRQ Patient Safety Indicators (PSIs). Similar to past research, the findings highlight the potential for specific preventive strategies that may benefit this patient population.
Khuri SF, Henderson WG, Daley J, et al. Ann Surg. 2008;248:329-36.
The Patient Safety in Surgery study documented remarkable improvements in postoperative outcomes at Veterans Affairs hospitals following implementation of a quality improvement program. This study demonstrated similar improvement in clinical outcomes, including surgical site infection rates, following implementation of the program in private sector hospitals.
J Am Coll Surg. 2007;204(6):1087-1300.
… Surg. 2007;204(6):1087-1300. … KS … FE … MM … SF … WG … S. … JS … RT … AL … KK … TL … CJ … VB … L. … JB … DB … TD … … … Grunwald … Main … Pratte … Kinney … Stoner … Steiner … Fink … Cavender … Nowels … Wittgen … Mosca … KS Rowell … FE Turrentine … MM Hutter … SF Khuri … WG Henderson … S. Virani … JS Michaelson … RT Lancaster … AL Warshaw … KK …