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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 - 19 of 19 Results

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.
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.
Sinkowitz-Cochran R, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-43.
The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.
Landrigan CP, Parry G, Bones CB, et al. N Engl J Med. 2010;363:2124-34.
… The New England journal of medicine … N Engl J Med … Despite the past decade's intense focus on patient … medical records from 10 North Carolina hospitals over a 6-year period, using the Institute for Healthcare … of the state of the field, including a commentary by Dr. Robert Wachter and a plenary session at the National Patient …
Pingleton SK, Davis DA, Dickler RM. Am J Med Qual. 2010;25:305-11.
A recent report by the National Patient Safety Foundation challenged residency programs to train housestaff in patient safety and quality improvement. This study finds that, in addition to formal curricula, residents are increasingly learning patient safety principles through informal and hidden curricula in teaching hospitals.
Grissinger MC, Hicks RW, Keroack MA, et al. Jt Comm J Qual Patient Saf. 2010;36:195-202.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse … events despite their known limitations . Heparin is a high-risk medication that frequently generates incident …
Kaushal R, Bates DW, Abramson EL, et al. Am J Health-Syst Pharm. 2008;65:1254-1260.
Medication errors are common in pediatric inpatients, but the best method of addressing them remains unclear. Studies of technological interventions, such as computerized provider order entry, have yielded inconsistent results. In this controlled trial, clinical pharmacists were deployed in the intensive care unit (ICU) and general medical and surgical wards in a pediatric hospital, and their effect on prevention of medication errors was assessed. Serious medication errors (including near misses) were significantly reduced in the ICU. No effect was seen on medication error rates for general ward patients, although the baseline rate of errors was much lower in those areas. A prior review documented the effectiveness of pharmacists at preventing medication errors in a variety of inpatient settings.
Keroack MA, Youngberg BJ, Cerese JL, et al. Acad Med. 2007;82:1178-86.
Academic medical centers (AMCs) face unique challenges in translating their innovation in safety and quality research into clinical performance. This study examined discharge data from 79 AMCs to generate a scoring method for measures of safety, mortality, clinical effectiveness, and equity of care. After identifying three top performers and three average performers, a group of surveyors visited each site without knowledge of their score and made an objective assessment of the factors associated with their performance. The authors highlight the importance of a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration as key predictors of top performers. Similar to a past study that evaluated safety culture in AMCs, the authors emphasize that the actions of senior executives and department chairs do impact care at the bedside.
Kaushal R, Goldmann DA, Keohane C, et al. Ambul Pediatr. 2007;7:383-9.
The incidence of adverse drug events (ADEs) among children has been well characterized in hospital inpatients, but less studied in the outpatient setting. Conducted at six pediatric outpatient practices, this AHRQ-funded prospective cohort study evaluated the frequency of medication errors via chart review, review of prescriptions, and patient surveys. The overall rate of preventable ADEs was similar to a prior outpatient study, but nearly three-quarters of events were attributable to errors in administering drugs by the parents. Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading the authors to conclude that communication between clinicians and parents around the issue of medication side effects must be improved.
Sharek PJ, Horbar JD, Mason W, et al. Pediatrics. 2006;118:1332-40.
… events (AEs), have been used to screen for errors in a variety of clinical settings . This AHRQ–funded study used methodology similar to a prior study in adult intensive care unit patients to develop a chart-based set of triggers for error identification in the …