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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 30 Results
Arbaje AI, Greyson S, Keita Fakeye M, et al. J Patient Saf Risk Manag. 2023;28:201-207.
Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.
Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.
Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.
Oberlander T, Scholle SH, Marsteller JA, et al. J Healthc Qual. 2021;43:324-339.
… coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety … of patient safety practices . … Oberlander T, Scholle SH, Marsteller J, et al. Implementation of patient safety …
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Marsteller JA, Hsu Y-J, Chan KS, et al. BMJ Qual Saf. 2017;26:288-295.
The Team Checkup Tool stemmed from work done as part of the Keystone ICU project and is designed to identify barriers to the progress of quality improvement initiatives. In this study, investigators used focus groups and feedback sessions to assess the content of the tool. They conclude that the Team Checkup Tool measures meaningful aspects of team-based quality improvement work.
Marsteller JA, Wen M, Hsu Y-J, et al. Ann Thorac Surg. 2015;100:2182-9.
This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ Hospital Survey on Patient Safety Culture) than other surgical teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this study surgeons reported more optimal safety culture compared to nurses and perfusionists. This gap in perceived safety culture requires further study.
Hsu Y-J, Marsteller JA. Am J Med Qual. 2016;31:349-357.
To determine the impact of the Comprehensive Unit-Based Safety Program (CUSP) on patient safety, this study compared intensive care units participating in the program with units not participating. Although safety culture improved in units with CUSP implementation, the intervention did not reduce incidence of central line–associated bloodstream infections. These findings demonstrate that teamwork training approaches, while helpful, may not be sufficient to augment patient outcomes. Further study characterizing sites that improved versus those that did not may elucidate facilitators and barriers to achieving patient safety goals.
Dietz AS, Pronovost P, Mendez-Tellez PA, et al. J Crit Care. 2014;29:908-14.
Improving teamwork and communication is a continued focus in the hospital setting. This systematic review revealed that although studies of teamwork in the intensive care unit abound, the field lacks common definitions and constructs. Teamwork usually entailed joint strategy and shared goals, and quality improvement approaches to enhance teamwork typically involve team training and development of structured protocols. Many interventions target rounds, during which interdisciplinary providers discuss each patient, or handoffs between clinicians. The authors suggest that communication is the most prominent aspect of teamwork and propose further study in conceptualizing teamwork to design effective interventions. The heterogeneity in defining and measuring teamwork may account for mixed results in improving safety outcomes. An AHRQ WebM&M perspective describes the Veterans Health Administration's medical team training program.
Thompson DA, Marsteller JA, Pronovost P, et al. J Patient Saf. 2015;11:143-51.
… of patient safety … J Patient Saf … This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery … surveys, ethnographic direct observation, and analysis of a large database. Safety culture , teamwork and communication …
Michtalik HJ, Pronovost P, Marsteller JA, et al. J Hosp Med. 2013;8:644-6.
In this national survey of attending hospitalists, 40% of respondents reported an unsafe, high workload at least once in the prior month. Physicians working without midlevel assistance or housestaff were more likely to report an unsafe workload, and those working within systems with census control (patient caps, fixed bed capacity, or staff augmentation plans) were less likely to report an unsafe workload.
Marsteller JA, Sexton B, Hsu Y-J, et al. Crit Care Med. 2012;40:2933-9.
… in Michigan through use of an evidence-based checklist and a comprehensive unit-based safety program . However, as a pre–post cohort study, it was unable to clearly establish a causal relationship between the intervention and the …
Hudson DW, Holzmueller CG, Pronovost P, et al. Am J Med Qual. 2012;27:201-9.
… reporting and root cause analysis . This commentary draws a contrast between this approach and that used in the nuclear … focuses on prospective error detection through the use of a robust peer-to-peer assessment process. Nuclear power … by an independent non-regulatory body, which conducts a detailed safety assessment and makes specific …