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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 - 11 of 11 Results
Pfeiffer Y, Atkinson A, Maag J, et al. J Patient Saf. 2023;19:264-270.
Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.
Buetti N, Marschall J, Drees M, et al. Infect Control Hosp Epidemiol. 2022;43:553-569.
Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.
Salmasian H, Blanchfield BB, Joyce K, et al. JAMA Netw Open. 2020;3:e2019652.
Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.  
Weiner SG, Baker O, Poon SJ, et al. Ann Emerg Med. 2017;70:799-808.e1.
This pre–post study examined the effect of a change in emergency department opioid prescribing guidelines in Ohio in 2012. The quantity of opioid prescriptions from emergency departments and the duration of opioid prescriptions declined. The authors attribute these declines to the more stringent prescribing guideline and advocate for spreading such policies to improve opioid safety.
Griffey RT, Schneider RM, Adler L, et al. J Patient Saf. 2016;16:e11-e17.
Researchers sought to develop an emergency-department specific trigger tool to identify adverse events. Their Delphi process resulted in a 46-item proposed tool that will require validation and testing in order to determine its usefulness in practice. This formative work fills a gap in available trigger tools.
Aaronson E, Wittels KA, Nadel ES, et al. West J Emerg Med. 2015;16:810-7.
This survey of emergency medicine residency program directors revealed wide variability in the structure and emphasis of morbidity and mortality (M&M) conferences, a key component of patient safety training for graduate medical education. Not all conferences supported a blame-free approach to errors or included follow-up to errors, suggesting that M&M conferences could be better designed to support safety culture.
Liang SY, Theodoro DL, Schuur JD, et al. Ann Emerg Med. 2014;64:299-313.
Emergency care presents risks of health care–associated infection (HAI) for both clinicians and patients. This review provides an overview of HAIs in the emergency setting, including standard precautions meant to prevent the spread of infections, strategies to reduce risk of HAIs related to medical device use, and the evidence around effectiveness of prevention programs.

Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801.

Preventing healthcare-acquired infections (HAIs) remains a patient safety priority. Based on a collaborative effort led by the Society for Healthcare Epidemiology in America (SHEA) and the Infectious Diseases Society of America (IDSA), this practice guideline builds on previous work and summarizes strategies to prevent common HAIs (i.e., catheter-associated urinary tract infections, Clostridium difficile infections, surgical site infections, central line-associated bloodstream infections, methicillin-resistant Staphylococcus aureus infections, and ventilator-associated pneumonia) as well as strategies to increase hand hygiene to prevent HAIs.
Horwitz LI, Meredith T, Schuur JD, et al. Ann Emerg Med. 2009;53:701-10.e4.
Prior research has found that the transfer of patients from the emergency department (ED) to inpatient wards can be a source of errors. This survey of ED and hospitalist staff at an academic medical center solicited examples of adverse events associated with the ED–inpatient transition. The examples cited revealed many root causes, ranging from lack of a standardized signout process to environmental factors (such as ED overcrowding) and failure to assign responsibility (eg, when an admitted patient is "boarded" in the ED while awaiting a floor bed). The study authors provide suggestions for system improvements to prevent and ameliorate adverse events associated with this care transition.