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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 - 10 of 10 Results
Casalino LP, Li J, Peterson LE, et al. Health Aff (Millwood). 2022;41:549-556.
Physician burnout has been associated with higher rates of self-reported medical errors and increased costs related to physician turnover. This analysis linked survey data from family physicians to Medicare claims to explore any association of burnout with four objective measures of care outcomes (ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs). There was no consistent, statistically significant relationship between burnout and the four measures of care outcomes and further research on this relationship is warranted.
Arntson E, Dimick JB, Nuliyalu U, et al. Ann Surg. 2021;274:e301-e307.
Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare & Medicaid Services (CMS) reduce payments to hospitals with the highest rates of these conditions through its Hospital-Acquired Condition Reduction Program (HACRP). This study evaluated surgical HACs at three timepoints: before Affordable Care Act (ACA) implementation, after ACA implementation, and after HACRP. While the number of HACs continued to decline after implementation of HACRP, it did not affect 30-day mortality.
Sheetz KH, Dimick JB, Englesbe MJ, et al. Health Aff (Millwood). 2019;38:1858-1865.
Since 2013, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) has reduced payments to hospitals with elevated rates of specific outcomes deemed to be preventable sources of harm. To better understand the impact of the HACRP in Michigan, this study used a surgical registry to compare trends in rates of outcomes targeted by the program to concurrent trends for other hospital-acquired conditions, such as postoperative cardiac arrest and postoperative pneumonia. The authors saw an overall decrease in all hospital-acquired conditions over the eight-year study period but did not identify a statistically significant change in the rate of HACRP-targeted versus non-targeted conditions. The authors acknowledge that these findings may not be generalizable nationally because of robust quality improvement efforts already in place in Michigan, such as existence of other quality improvement efforts, such as the AHRQ-recognized Michigan Surgical Quality Collaborative and the Hospital Engagement Network
Sankaran R, Sukul D, Nuliyalu U, et al. BMJ. 2019;366:l4109.
The Centers for Medicare and Medicaid Services impose financial penalties on hospitals whose Medicare patients experience higher rates of hospital-acquired conditions (HACs) like urinary tract infections and pneumonia. Hospitals caring for more patients with low socioeconomic status receive more penalties under this program than hospitals caring for wealthier populations. Investigators attempted to assess whether hospitals penalized under the program reduced HAC rates. They found that penalized hospitals did not have lower HAC rates or improve other measures of clinical quality. This finding raises questions about whether financial penalties effectively enhance patient safety. By contrast, quality improvement collaboratives like Partnership for Patients have markedly reduced HACs. A PSNet interview with former AHRQ director Andrew Bindman explored strategies for reducing health care–acquired harm in the hospital and ambulatory settings.
Scally CP, Ryan AM, Thumma JR, et al. Surgery. 2015;158:1453-61.
Duty hour reform was enacted to improve patient safety, but its effect remains unclear. This study found no difference in surgical complication rates before and after implementation of 2011 duty hour reforms, using nonteaching hospitals as a reference population. These results add to the literature suggesting that duty hours had no substantial impact on patient outcomes.
Osborne NH, Nicholas LH, Ryan AM, et al. JAMA. 2015;313:496-504.
This large study used 9 years of national fee-for-service Medicare data to examine differences in surgical outcomes between hospitals participating in the National Surgical Quality Improvement Program (NSQIP) and nonparticipating hospitals. There was no statistically significant difference in the rate of improvement for any of the measured outcomes—risk-adjusted 30-day mortality, serious complications, reoperation, or 30-day readmissions—at 1, 2, or 3 years after enrollment in NSQIP versus well-matched controls. Notably, over 6 years there has been a trend toward reductions in mortality, serious complications, and readmissions across hospitals, regardless of NSQIP participation. The results of this study strengthen those of the study by Etzioni and colleagues in the same issue of the Journal of the American Medical Association. In an accompanying editorial, Dr. Donald Berwick states, "it is implausible to conclude that knowing results is not useful—perhaps essential—for systematic improvement of outcomes," but that hospitals must realize measurement alone is insufficient.