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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 202 Results
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.
King C, Dudley J, Mee A, et al. Arch Dis Child. 2023;Epub Feb 15.
Medication errors in pediatric patients can have serious consequences. This systematic review identified three studies examining interventions to improve medication safety in pediatric inpatient settings. Although the three interventions – a mnemonic device, a checklist, and a specific prescribing round involving a clinical pharmacist and a doctor – reduced prescribing errors, the studies did not assess weight-based errors or demonstrate reductions in clinical harm.
Jafri FN, Yang CJ, Kumar A, et al. Simul Healthc. 2023;18:16-23.
In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.
Merchant NB, O’Neal J, Dealino-Perez C, et al. Am J Med Qual. 2022;37:504-510.
The goal for health care organizations to attain high reliability is established but elusive. This article shares insights drawn from a Veterans’ Health system effort to support high reliability. The approach used centered on five components focusing on leadership, data systems, implementation, training, and safety culture.

Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Pub. No.22(23)-0065-1.

Research has shown that involving patients, their families and caregivers, in the planning, delivery, and evaluation of their healthcare can improve safety and quality. This collection of AHRQ-funded work includes summaries of 53 projects since 2000 that contributed to environments in which patients, families, and healthcare professionals work together to improve the quality and safety of care. Efforts highlighted include those involving patients and families in activities designed to report and ultimately prevent medical errors and near misses.

R3 Report. December 20, 2022;38:1-8.

Health care inequities persist despite increasing awareness they negatively affect quality, safety, and patient centeredness. This article shares the Joint Commission strategy for embedding equity improvement into the National Patient Safety Goal initiative to increase focus on equity as a safety priority across all care environments.
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Moon SEJ, Hogden A, Eljiz K. BMJ Open Qual. 2022;11:e002057.
Health systems often implement innovative quality improvement and patient safety initiatives, but the longevity and sustainability of these initiatives remains a challenge. This scoping review explored the factors which enable and hinder sustainability of hospital-wide quality improvement (QI) initiatives. Three overarching themes were identified – the role of (1) people, including the organizational and leadership teams, as well as frontline staff implementing the QI initiatives, (2) processes, such as local and organizational integration and planning for sustainability, and (3) the organizational environment such as resources, infrastructure, and hospital culture.
Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.
Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.
Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.
Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.
Agarwal AK, Sagan C, Gonzales R, et al. J Am Coll Emerg Physicians Open. 2022;3:e12870.
Black patients who report experiencing racism in healthcare report poorer quality of care. In this text-message based study, Black and White patients discharged from the emergency department (ED) were asked about their overall quality of care and whether they perceived an impact of their race on their care. While Black patients reported high overall quality of care, 10% believed their race negatively impacted their care. The authors highlight the importance of asking about the impact of race on care to identify and reduce potential disparities.

Collaborative for Accountability and Improvement. January 26, 2023.

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session discussed challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.
Thusini S’thembile, Milenova M, Nahabedian N, et al. BMC Health Serv Res. 2022;22:1492.
Health systems often consider return on investment (ROI) when considering implementation of quality improvement and patient safety interventions (i.e., costs saved by preventing medical errors or improving quality of care). This systematic review explored how ROI concepts have been used in studies assessing large-scale quality improvement programs.
Dynan L, Smith RB. Health Serv Res. 2022;57:1235-1246.
Nurses play a critical role in ensuring patient safety, and prior research has shown that better nurse-staffing ratios and nurse engagement can improve mortality rates. This study of nearly 300 Florida acute-care hospitals evaluated the effect of expenditures on continuing nurse education staffing ratios of several AHRQ Patient Safety Indicators (PSI). Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers, and deep vein thrombosis.
Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.
The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.
Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Childs E, Tano CA, Mikosz CA, et al. Jt Comm J Qual Patient Saf. 2023;49:26-33.
In response to the increase in opioid deaths, the Centers for Disease Control and Prevention (CDC) released the Guidelines for Prescribing Opioids for Chronic Pain in 2016, with an update released in 2022. This study reports on the CDC Opioid QI Collaborative which was launched to identify successful evidence-based strategies for implementing the guidelines. The challenges and strategies described in the publication can be used by health systems to accelerate implementation of the guidelines.
Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.
Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.