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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 - 15 of 15 Results
Hawkins RB, Nallamothu BK. BMJ Qual Saf. 2023;32:181-184.
A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.
Gilmartin HM, Langner P, Gokhale M, et al. J Nurs Care Qual. 2018;33:53-60.
In a robust safety culture, nurses and other health care workers feel comfortable reporting safety hazards without fear of repercussions. This study found no relationship between nurse-reported psychological safety and adherence to a central line insertion checklist in the Veterans Affairs system. A recent PSNet interview with Linda Aiken discussed what investments in the nursing workforce yield the biggest safety impacts.
Gupta A, Allen LA, Bhatt DL, et al. JAMA Cardiol. 2018;3:44-53.
Readmissions are a focus of patient safety efforts, especially in light of Medicare's nonpayment policy. This retrospective, interrupted time-series analysis examined whether reduction in readmissions for heart failure led to any change in health outcomes. This study analyzed data from a national clinical registry of patients with heart failure admitted between 2006 and 2014, spanning the implementation of Medicare nonpayment. Similar to prior studies, there was a decline in readmission rates observed after implementation of penalties. In this cohort, researchers also observed increases in 30-day and 1-year risk-adjusted mortality. The authors conclude that penalties for readmissions may have unintended negative consequences for patient outcomes. A previous PSNet interview discussed the benefits and limitations of Medicare's nonpayment policy.
Kachalia A, Mello MM, Nallamothu BK, et al. Circulation. 2016;133:661-71.
This review explores policy and legal approaches to addressing care delivery problems, including strategies that focus on transparency, reimbursement, professional regulation, and tort reform. The authors suggest cardiologists are well-positioned as leaders in adopting these approaches because the conditions they treat are highly visible, common, and expensive.
Mehta RH, Chen AY, Alexander KP, et al. Circulation. 2015;131:980-7.
Guidelines for the care of patients with acute coronary syndromes recommend aggressive therapy with certain medications, such as antiplatelet therapies that carry a risk of bleeding complications. This cohort study found only a weak relationship between quality (measured as adherence to guideline-recommended therapy) and safety (measured as major bleeding rates) at the individual hospital level. Hospitals that maximized both quality and safety had the best patient outcomes.
Salisbury AC, Reid KJ, Alexander KP, et al. Arch Intern Med. 2011;171:1646-53.
This study discovered that blood loss from greater use of phlebotomy was independently associated with hospital-acquired anemia. An accompanying editorial [see additional link below] discusses this hazard of hospitalization in the context of more than just never events.
Michaels AD, Spinler SA, Leeper B, et al. Circulation. 2010;121.
Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.
Tsai TT, Maddox TM, Roe MT, et al. JAMA. 2009;302:2458-64.
Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.
Masoudi FA, Magid DJ, Vinson DR, et al. Circulation. 2006;114:1565-71.
The investigators studied medical records of heart attack victims and found that 12% did not have their tests interpreted correctly in the emergency room and did not receive appropriate care for acute myocardial infarction.
Alexander KP, Chen AY, Roe MT, et al. JAMA. 2005;294:3108-16.
Treatment of acute coronary syndromes (ACS) benefits from extensive research outlining evidence-based practices for improving the quality of such care. This study discovered that more than 40% of patients presenting with ACS received at least one dose of an antithrombotic medication outside the recommended dosing range. These excess doses lead to greater risks of bleeding; the investigators estimate that 15% of patients experience major bleeding due to these prescribing errors. The findings suggest an alarmingly high rate of potential errors and adverse outcomes for ACS patients. The risks also seem directed at vulnerable populations such as elderly patients with specific comorbidities (eg, diabetes, renal insufficiency, and heart failure). With appropriate increases in utilization of antithrombotic agents for conditions such as ACS, greater attention must focus on safe initial dosing practices to prevent adverse drug events.