Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 8 of 8 Results
Blythe R, Parsons R, White NM, et al. BMJ Qual Saf. 2022;31:725-734.
Early recognition of clinical deterioration in patients is often difficult to detect and often results in poor patient outcomes. This scoping review focused on the delivery and response to deterioration alerts and their impact on patient outcomes. Only four out of 18 studies included in the review reported statistically significant improvements in at least two patient outcomes, Authors suggest that workflow and integration of the early warning system model’s features into the decision-making process may be helpful.
Hill A-M, Jacques A, Chandler M, et al. Jt Comm J Qual Patient Saf. 2019;45:91-97.
This prospective observational study found that patients who experienced a fall with injury had longer hospital stays and higher likelihood of discharge to a location other than home compared to age- and unit-matched control patients. This study lends weight to fall prevention as a patient safety priority.
Barker AL, Morello RT, Wolfe R, et al. BMJ. 2016;352:h6781.
Falls in hospitalized patients are a common source of preventable harm, and the incident is considered a never event when it results in serious injury. Conducted at six Australian hospitals, this cluster randomized controlled trial sought to evaluate the effectiveness of a bundled intervention on the incidence of falls on adult wards. The bundle included assessing patients' risk for falling along with several widely used tactics to prevent falls. Despite successful implementation of the fall prevention bundle, falls occurred just as frequently on intervention wards as control wards. This study is an important example of the need to rigorously evaluate safety interventions, even those that have high face validity. The authors conclude that since these interventions appear ineffective, organizations should consider disinvestment in these practices because completing ineffective interventions consumes a significant amount of staff time and effort. A WebM&M commentary discussed a case involving a fall resulting in injury.
Hoffmann TC, Del Mar C. JAMA Intern Med. 2015;175:274-286.
This systematic review found that patients generally overestimate benefits and underestimate harms related to tests and treatments. The topics studied included cancer, surgery, cardiovascular disease, fetal–maternal medicine, and medications. These findings suggest that unrealistic patient expectations may contribute to health care overuse.
Haines TP, Hill A-M, Hill KD, et al. Arch Intern Med. 2011;171:516-24.
Efforts to prevent falls among hospitalized patients have been limited by a lack of evidence-based preventive strategies. In this study conducted at two Australian hospitals, cognitively intact patients who received a multimodal fall prevention intervention (written and video-based educational materials on falls and physical therapist follow-up) were significantly less likely to fall during hospitalization. The fall prevention evidence base was also augmented by a recent study that used an individualized fall prevention strategy to sharply reduce falls in geriatric inpatients. A case of recurrent falls is discussed in an AHRQ WebM&M commentary.