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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 25 Results
Cohen TN, Berdahl CT, Coleman BL, et al. J Nurs Care Qual. 2023;Epub May 9.
Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.
Skeff KM, Brown-Johnson CG, Asch SM, et al. J Healthc Manag. 2022;67:339-352.
Electronic health records (EHRs) can improve patient safety but can also contribute to physician burnout. This qualitative study involving physicians and medical trainees found that distress most often occurred when physicians were prioritizing systems-based practice (e.g., EHR-required documentation) over other professional activities, such as patient care, communication, and practice-based learning.  
McCleskey SG, Shek L, Grein J, et al. BMJ Qual Saf. 2022;31:308-321.
Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.
Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8:100496.
Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.
Leback C, Johnson DH, Anderson L, et al. Infect Control Hosp Epidemiol. 2018;39:841-848.
This direct observation and interview study identified barriers to and facilitators of safe injection practices in outpatient care. Inadequate time and staffing inhibited safe injection practices. The availability of safety needles and prefilled syringes improved the use of safe practices. The authors note that knowledge of safe injection practices does not ensure sufficient implementation.
Merrell SB, Gaba DM, Agarwala A, et al. Jt Comm J Qual Patient Saf. 2018;44:477-484.
Emergency manuals have been adopted from high reliability industries as a cognitive aid for guiding interprofessional teams during clinical crises. Investigators interviewed emergency manual users after an intraoperative cardiac arrest and conceptualized how the manual helped provide optimal care. A PSNet interview reviews more broadly how to achieve high reliability in health care.
Tedesco D, Asch SM, Curtin C, et al. Health Aff (Millwood). 2017;36:1748-1753.
Using data from the Healthcare Cost and Utilization Project, this retrospective secondary data analysis found an overall increase in opioid-related hospital visits, with a peak in 2010 and gradual decline since then. Coincident with the decline in opioid-related visits, a sharp rise in heroin-related hospital visits emerged. These results underscore the concern that tighter controls on opioid medications may lead to heroin use.
Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.
Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.
Wagner TH, Taylor T, Cowgill E, et al. BMJ Qual Saf. 2015;24:295-302.
Large-scale adverse events are those in which a group of patients are exposed to a risk of infection. Disclosure and notification of patients in such cases is complicated by the lack of relationship between the notifying clinician and patient. The Veterans Affairs (VA) medical centers examined patient utilization from administrative data following notification of a possible exposure to a bloodborne pathogen. Compared to reference patients, those notified of a possible exposure were more likely to be tested for bloodborne pathogens. African American patients were less likely to undergo blood testing for exposures compared to white patients, adding to concerns about disparities in patient safety. Those patients exposed to a large-scale adverse event during dental care were more likely to seek non-VA dental care in the short term, but most returned to the VA within 18 months of the exposure, suggesting some loss of trust that resolves over time.
Perspective on Safety September 1, 2011
… involve issues with physician or multidisciplinary care. … Teryl K. Nuckols, MD, MSHS … Associate Professor, Division of General …
This piece discusses incident reporting systems as tools for improving patient safety.
A leading expert on evidence-based patient safety strategies and translating research into practice, Dr. Shojania is the Director of the University of Toronto Centre for Patient Safety and the new editor of BMJ Quality and Safety.
Buntin MB, Burke MF, Hoaglin MC, et al. Health Aff. 2011;30:464-471.
This systematic review of health information technology (IT) studies found that most published studies reported positive effects on a variety of outcomes, ranging from patient safety to provider satisfaction and the effectiveness of care. This review extends and corroborates findings from a previous review published in 2006. Despite the benefits of health IT, both hospitals and clinics have been slow to implement comprehensive electronic health records, and the negative studies included in this review provide important insights into difficulties encountered while implementing health IT.
Nuckols TK, Bell D, Liu H, et al. Qual Saf Health Care. 2007;16:164-8.
Despite mandates for US hospitals to maintain incident reporting systems, little is known about the utility of the data collected. This study linked incident report and discharge databases at two hospitals to examine how frequently reports were filed and what types of incidents were documented. The vast majority of reports were filed by nurses, with less than 2% filed by physicians (a problem noted in prior research). This pattern likely influenced the spectrum of problems reported; only a small proportion of reported incidents related to procedures. A prior commentary proposed a theoretical framework for using incident reporting data to improve safety.