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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 - 16 of 16 Results
Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.
After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.
Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;37:1075-1081.
Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.
Sauro KM, Soo A, de Grood C, et al. Crit Care Med. 2020;48:946-953.
Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.
Stelfox HT, Soo A, Niven DJ, et al. JAMA Intern Med. 2018;178:1390-1399.
This retrospective observation cohort study conducted at nine hospitals sought to determine whether discharge from the intensive care unit (ICU) directly to home affected odds of readmission within 30 days or mortality within 1 year. Overall, patients discharged from the ICU to home are younger and less ill than patients who are transferred from the ICU to the hospital ward before returning home. The proportion of patients discharged from ICU to home varied widely by site. When researchers compared patients discharged from ICU to home to patients of similar age and severity of illness upon ICU admission who were discharged home from the hospital ward, they found no differences in odds of readmission or mortality. A related commentary explores why discharges from ICU to home occur and calls for implementing care transitions best practices upon ICU discharge in order to support optimal patient outcomes and prevent readmissions.
Fernando SM, Reardon PM, Bagshaw SM, et al. Crit Care. 2018;22:67.
Patients evaluated by a rapid response team at night were less likely to be transferred to the intensive care unit and more likely to die in the hospital compared to patients evaluated during the daytime. A previous WebM&M commentary discussed a preventable adverse event occurring in part due to less intensive nighttime staffing.
WebM&M Case April 1, 2017
… them with a smile and a wink, "Hey, when it's my time, I'm fired up and ready to go!" … The Commentary … by Daren K. Heyland, MD, MSc … This case centers around an older … Care. 2017;7:292-299. [Available at] 11. Heyland DK, Frank C, Groll D, et al. Understanding cardiopulmonary …
Conn LG, Haas B, Rubenfeld GD, et al. J Surg Educ. 2016;73:639-47.
According to this qualitative study at a single academic institution, staff surgeons and intensivists frequently exclude resident physicians from patient care conversations. Reasons included lack of trust, need for timely communication, and a perception that residents cannot adequately contribute to decision making. This finding has important implications for the integration of communication training during medical education.
Heyland DK, Ilan R, Jiang X, et al. BMJ Qual Saf. 2016;25:671-9.
Discordance between patient preferences for end-of-life care and documentation of their wishes is a common problem in hospitals. Such events have been described as silent misdiagnoses and may be classified as medical errors. This audit study across 16 hospitals in Canada quantified how often medical orders for life-sustaining treatments do not match patient preferences. Only 2% of patients who reported a preference for cardiopulmonary resuscitation (CPR) had CPR withheld in their medical orders; whereas, 35% of patients who wished to forgo CPR had orders to receive it in the event of an arrest. This mismatch represents a considerable source of potential overtreatment, which may result in numerous adverse downstream effects. A previous WebM&M commentary discussed tools for eliciting end-of-life preferences.
Parshuram CS, Amaral ACKB, Ferguson ND, et al. CMAJ. 2015;187:321-9.
This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.
Heyland DK, Barwich D, Pichora D, et al. JAMA Intern Med. 2013;173:778-787.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Dodek P, Wong H, Heyland DK, et al. Crit Care Med. 2012;40:1506-12.
A positive safety culture has been linked to improved staff satisfaction as well as a lower incidence of errors. This study, conducted in 23 Canadian intensive care units (ICUs), sought to examine the relationship between safety culture and families' satisfaction with care. The authors found a strong positive correlation between safety culture and family satisfaction with care among a subset of patients who had prolonged and ultimately fatal ICU stays. This finding implies that families of patients who have lengthy hospitalizations are affected by the safety and organizational culture of the units where their loved ones are being cared for and that improving safety culture may also improve patient and family satisfaction with care.
Jones D, Bagshaw SM, Barrett J, et al. Crit Care Med. 2012;40:98-103.
In this study, conducted at seven hospitals in three countries, nearly one-third of patients seen by a rapid response team ultimately had limitations placed on their care (such as do-not-resuscitate orders). This finding indicates a need for improved advanced care planning.
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-7.
Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.
Bagshaw SM, Mondor EE, Scouten C, et al. Am J Crit Care. 2010;19:74-83.
Nurses in this study valued medical emergency team (MET) systems, but they also pointed out barriers to activation, including fear of criticism and adherence to the more traditional model of contacting the responsible physician first. Fear of criticism was a finding not reported in a past study of nursing attitudes about MET systems.