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
Approach to Improving Safety
Displaying 1 - 20 of 33 Results
Jha AK. JAMA. 2017;318:1429-1430.
Public reporting efforts focused on surgeons have received mixed responses from both the profession and the public. This commentary argues that reporting outcomes at the individual, rather than organizational, level is important to help patients make decisions regarding provider choice and establish surgeon accountability for the safety and quality of their practice. A PSNet perspective discussed accountability in patient safety.
Wang DE, Tsugawa Y, Figueroa JF, et al. JAMA Intern Med. 2016;176:848-50.
Centers for Medicare and Medicaid Services star ratings are based on patient experience surveys, and the relationship between such ratings and patient outcomes has not been well-established. This secondary data analysis found that hospitals with higher star ratings had lower 30-day mortality and readmission rates. The authors suggest that these ratings may lead patients to higher-performing hospitals.
Jha AK, Pronovost P. JAMA. 2016;315:1831-2.
In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.
Austin M, Jha AK, Romano PS, et al. Health Aff (Millwood). 2015;34:423-430.
One strategy to improve patient safety is public reporting of performance data, and hospital quality ratings have proliferated. In this study, researchers examined the extent of agreement among hospital ratings issued by U.S. News & World Report, HealthGrades, The Leapfrog Group, and Consumer Reports. Each rating system has a different emphasis, varying inclusion and exclusion criteria, and focuses on different measures of quality. There is very little agreement among the ratings for either high or low performance—not one hospital was rated as a top performer across all four ratings—which makes these ratings challenging for consumers to interpret or use in decision making. These findings are consistent with prior work demonstrating variability in surgical quality rankings. The authors call for transparency in how ratings are constructed and clear communication with consumers to facilitate informed decisions regarding their care. A recent AHRQ WebM&M interview with Leah Binder, President and CEO of The Leapfrog Group, explored the development of the Hospital Safety Score and Leapfrog Hospital Survey.
Pronovost P, Jha AK. N Engl J Med. 2014;371:691-693.
In this commentary, the authors raise concerns about the validity of large-scale reductions in patient harms and readmissions reported by the Partnership for Patients Hospital Engagement Networks initiative. They describe how lack of standardized measures and peer review to evaluate the interventions may affect the reliability of the results.
Joynt KE, Le ST, Orav J, et al. JAMA Intern Med. 2014;174:61-7.
This study found no association between hospital chief executive officer (CEO) compensation and mortality rates or readmissions. However, hospitals with higher CEO compensation had significantly more advanced technology and higher patient satisfaction scores.
Jha AK, Larizgoitia I, Audera-Lopez C, et al. BMJ Qual Saf. 2013;22:809-15.
In countries where access to health care remains a significant problem, emphasizing patient safety may seem like a luxury. However, this study demonstrates that adverse events due to health care are a major contributor to the global burden of disease in lower-income countries and advocates for greater emphasis on evaluating and improving the safety of care in resource-poor settings. Per this analysis, preventable harm ranks as the 20th most common source of overall morbidity and mortality worldwide—and as this measure is based on harm caused by seven specific adverse events, it is likely an underestimate. The World Health Organization has taken a prime role in improving patient safety worldwide, with one of its leading accomplishments being development of the Surgical Safety Checklist.
Hsiao C-J, Jha AK, King J, et al. Health Aff (Millwood). 2013;32:1470-7.
This survey found that by 2012, 72% of ambulatory-based physicians in the United States had implemented some form of electronic health record and 40% were using computerized provider order entry. These figures represent a substantial increase over the past several years.
DesRoches CM, Charles D, Furukawa MF, et al. Health Aff (Millwood). 2013;32:1478-85.
Despite considerable federal financial incentives intended to promote electronic health record (EHR) use, as of 2012 only 42.2% of hospitals in the United States had implemented a system that met federal "meaningful use" criteria (which include use of computerized provider order entry with decision support). Rural and nonteaching hospitals were less likely to have implemented an EHR compared with larger urban hospitals.
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.
Nakamura MM, Ferris T, DesRoches CM, et al. Arch Pediatr Adolesc Med. 2010;164:1145-51.
This study highlights the slow adoption of electronic health records in children's hospitals, with less than 3% having a comprehensive system in place. Hospital characteristics were not associated with implementation, and financing was the most important policy strategy identified to promote use.
Ly DP, López L, Isaac T, et al. Med Care. 2010;48:1133-1137.
Hospitals that serve a higher proportion of African American patients had consistently higher rates of patient safety events (as measured by the AHRQ Patient Safety Indicators). The safety events occurred at higher rates in both black and white patients at these hospitals. An AHRQ WebM&M interview discusses the unique challenges of patient safety in safety net hospitals.
Isaac T, Zaslavsky AM, Cleary PD, et al. Health Serv Res. 2010;45:1024-40.
The patient's role in quality and safety improvement efforts has focused on tips recommended to keep patients safe and mechanisms to engage them with patient-centered strategies. Although past research suggests that patient complaints relate more to service quality rather than quality of care, debate about this relationship persists. This study advances our understanding by examining patient perceptions of care, measured through a validated survey tool, and technical measures of quality and safety, measured through Hospital Quality Alliance data and the AHRQ Patient Safety Indicators (PSIs). Patients' overall rating and "likelihood to recommend" a hospital had strong associations with technical performance measures in more than 900 hospitals. The authors highlight the limitations in their detailed analysis and advocate for further research to better understand these relationships. However, their findings do add to the argument for greater patient-driven measures in assessing the quality of care provided.
Jha AK, Epstein AM. Health Aff (Millwood). 2010;29:182-7.
This study surveyed more than 700 board chairs and found that fewer than half rated quality as one of their top two priorities. Few board chairs reported any dedicated training in quality, and large differences were present between board activities in high-performing versus low-performing hospitals. The latter provides opportunities for future intervention and policy change.
Weingart SN, Simchowitz B, Shiman L, et al. Arch Intern Med. 2009;169:1627-1632.
E-prescribing is a growing solution to prevent medication errors, with insurers rewarding the practice and high-risk settings adopting the technology. This study surveyed more than 180 ambulatory providers who use e-prescribing systems and found that respondents believed the system improved the quality of care delivered, prevented errors, and enhanced both patient satisfaction and clinical efficiency. However, less than half the respondents were satisfied with the drug interaction and allergy alerts. The authors advocate for better design of alert systems to prevent alert fatigue yet promote safe prescribing practices. The challenges of implementing effective medication decision support systems are discussed in an AHRQ WebM&M perspective.