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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 22 Results
Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.
As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Greene MT, Gilmartin HM, Saint S. Am J Infect Control. 2020;48:2-6.
This cross-sectional study reports the results of an ongoing national survey of infection preventionists to assess hospital infection control program characteristics and organizational practices to prevent common healthcare-associated infections. One-third of responding hospitals reported characteristics of organizational safety culture (e.g. employee perceptions of feeling safe to speak up, ask for help, or provide feedback), which was associated with increased odds of using some recommended practices for preventing catheter-associated urinary tract infections and ventilator-associated pneumonia.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019;28:741-749.
This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.
Smith S, Snyder A, McMahon LF, et al. Health Aff (Millwood). 2018;37:1787-1796.
Hospital-acquired pressure ulcers (HAPUs) are considered a never event, represent a significant source of patient harm, and can result in loss of payment to hospitals. In this study, researchers analyzed administrative data from 3 states for 2009 to 2014. The HAPU incidence they found was about one-twentieth of the HAPU incidence detected using chart review. In addition, while both chart review data and administrative data showed a reduction in HAPU incidence for the study period, the decline using administrative data was almost entirely due to a decrease in the incidence of lower stage pressure ulcers. The authors suggest that using clinical data from chart review and taking ulcer severity into account may yield a more meaningful measurement strategy.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28:74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Smith SN, Greene MT, Mody L, et al. BMJ Qual Saf. 2017;27:464-473.
Measuring safety culture is a core patient safety activity, but the relationship between safety culture and adverse events remains unclear. This prospective cohort study measured nursing home safety culture using the AHRQ Nursing Home Survey on Patient Safety Culture and also measured rates of catheter-associated urinary tract infections (CAUTIs) as part of a quality improvement collaborative. Although safety culture survey results improved and CAUTIs declined over time, after accounting for other factors such as nursing home size and nonprofit versus for-profit status, there was no association between safety culture score and CAUTI rates. The authors recommend focusing on technical aspects of infection control such as standard protocols for catheter insertion rather than safety culture in order to improve patient safety outcomes. Correspondence published in the same issue points out limitations of a related study on the AHRQ Hospital Survey on Patient Safety Culture.
Banaszak-Holl J, Reichert H, Greene T, et al. J Am Geriatr Soc. 2017;65:2244-2250.
Prior studies have demonstrated that managers have more positive perceptions of safety culture than frontline staff across multiple health care settings. This study demonstrated that staff responses to AHRQ's Nursing Home Survey on Safety Culture were higher for administrators than for clinical staff. The authors call for reporting safety culture results by role rather than by facility.
Mody L, Greene T, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Mody L, Greene T, Saint S, et al. Infect Control Hosp Epidemiol. 2017;38:287-293.
The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.
Smith SN, Reichert HA, Ameling JM, et al. Med Care. 2017;55:606-614.
Hospital quality scores are publicly available, but the extent to which they reflect patient safety remains controversial. This study compared measures from the Leapfrog Group, which incorporates mandatory publicly reported data and voluntary self-reported data to give each hospital a letter grade, to mandatory publicly reported data on the Medicare's Hospital Compare website. Investigators found that most Leapfrog voluntary scores were close to perfect. For hospitals that did not report the voluntary component of the Leapfrog score, they modeled how the hospitals' overall letter grades would change if they had self-reported different performance levels. They found that self-reported data heavily influenced a hospital's letter grade. Leapfrog scores were not consistently associated with Hospital Compare data on hospital-acquired conditions like health care–associated infections, pressure ulcers, or falls. The authors suggest that Leapfrog data provides only a limited assessment of hospital performance.
Meddings J, Reichert H, Greene T, et al. BMJ Qual Saf. 2017;26:226-235.
Programs to prevent health care–associated infections (HAIs) have been some of the most prominent successes of the patient safety movement. These programs—including the Keystone ICU program and a recent effort to prevent catheter-associated urinary tract infections—have emphasized improving safety culture along with specific technical interventions. Analyzing data from two AHRQ-funded programs to prevent HAIs, this study sought to examine the relationship between Hospital Survey on Patient Safety Culture scores and HAI rates. Interestingly, no association was found between safety culture scores and HAI rates at the hospital unit level, even though HAI rates consistently improved during the study period. The authors note two possible interpretations of these results: first, safety culture may not be a crucial component of programs to reduce HAIs; second, survey results may not be an accurate measure of safety culture (especially in this study, where survey response rates were low). Other studies have indicated a stronger relationship between safety culture and rates of other types of adverse events. Therefore, despite this study's results, establishing a safety culture remains important.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.
Saint S, Fowler KE, Krein SL, et al. Infect Control Hosp Epidemiol. 2015;36:969-971.
Clostridium difficile infections are among the most serious health care–associated infections. In this study, most hospitals in the United States reported using C. difficile prevention measures, with the exception of antibiotic stewardship, which was in place at about half of hospitals surveyed. This finding underscores the need to focus on appropriate antibiotic use as part of patient safety efforts.
Singh H, Giardina TD, Petersen LA, et al. BMJ Qual Saf. 2011;21:30-38.
Diagnostic errors are a known threat to patient safety, and measuring their prevalence is challenging, particularly outside pathology and radiology settings. Past studies have highlighted classification systems and related prevention strategies, including the adoption of checklists. This study explored the use of a situational awareness (SA) framework to understand diagnostic errors in a primary care setting. Investigators interviewed providers involved in a diagnostic error and revealed that one level of SA was lacking (e.g., information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels). The authors found that applying the SA framework to analyze such errors provided deeper insight into the provider–work system interaction, which included important interface with the electronic health record. A past PSNet perspective and interview discussed diagnostic errors in medicine.