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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 41 Results
Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.
As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Schnipper JL. Ann Intern Med. 2022;175(8):ho2-ho3.

Medication reconciliation is a primary method for improving the safety of medication administration in acute care. This essay highlights how individual hospitalists can improve medication reconciliation both at the practice and organizational level. Areas of influence discussed include medication history completeness and health information technology design.
Patient Safety Innovation February 23, 2022

With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy.

Basco WT. JAMA Netw Open. 2018;1.
The number of hospitalists—physicians practicing exclusively in acute care settings—continues to grow. However, whether patient outcomes differ between hospitalists and general physicians remains unclear. This study examined medical record data from a single urban academic children's hospital to compare patient outcomes between general pediatricians and hospitalists. After adjustment for patient characteristics (e.g., age and number of chronic conditions) and for physician characteristics (e.g., number of years in practice), the investigators did not find differences in readmission rates, total costs, or lengths of stay. The hospitalists' patients had a greater risk for device-related adverse events, which was explained by differences in physician experience. The authors conclude that the safety of care delivered by general versus hospitalist pediatricians is similar. A related editorial predicts that the hospitalist model of pediatric acute care will continue to grow.
Perspective on Safety November 1, 2018
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
Goodwin JS, Salameh H, Zhou J, et al. JAMA Intern Med. 2017;178.
This analysis of Medicare data found that patients cared for by hospitalist physicians in their first year of practice have a slightly higher 30-day mortality risk than those treated by hospitalist physicians with more than one year of experience. The authors suggest that hospitalists in their first year in practice may require additional support in order to optimize patient outcomes.
Singh H, Zwaan L. Ann Intern Med. 2016;165:HO2-HO4.
Hospitalists have a key role in facilitating transitions and communication. This commentary discusses how hospitalists can prevent diagnostic errors and reviews opportunities for improvement, including encouraging patient involvement in their care and face-to-face team communication in difficult-to-diagnose cases.
Sokol-Hessner L, White AA, Davis KF, et al. J Hosp Med. 2016;11:245-250.
Although interhospital transfers are considered risky, they are not well characterized. This analysis of inpatient records found that even after adjustment for illness severity and patient characteristics, transferred patients had a higher risk of death compared with patients admitted through the emergency department. This finding should prompt prospective study of transfers to elucidate and address safety vulnerabilities.
O'Leary KJ, Turner J, Christensen N, et al. J Hosp Med. 2015;10:147-51.
Clinician discontinuity is often cited as a potential patient safety issue. However, this study found that transfers of care between hospitalists did not appear to be associated with adverse events. The authors note that as hospital care is provided within teams, research should focus on the effects of team complexity and changes on patient safety.
Schaffer A, Puopolo AL, Raman S, et al. J Hosp Med. 2014;9:750-5.
This review of closed malpractice claims found that hospitalists are less likely to be subject to malpractice claims than other internal medicine physicians and specialists. These findings counter the concern that hospitalists raise liability risk due to discontinuity of care. A related editorial suggests that an emphasis on diagnostic safety and interprofessional communication would improve safety in acute care settings with hospitalists.
Mittal VS, Sigrest T, Ottolini MC, et al. Pediatrics. 2010;126:37-43.
Nearly half of pediatric hospitalists in this survey reported conducting family-centered rounds—multidisciplinary rounds conducted at the bedside in the presence of the patient and family members. Among other benefits, family-centered rounds engage patients in patient safety.
Apker J, Mallak LA, Applegate B, et al. Ann Emerg Med. 2010;55:161-70.
This study reports on the development of a tool to assess the content and structure of handoff communications between emergency physicians and hospitalists. The authors found that the handoff communication was mostly "one-way," consisting primarily of information exchange without interactive questions and answers.
Scheurer D, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2009. ISBN: 9781599403045.
This book discusses the rise of the hospitalist movement within the context of quality and safety and reviews how hospitalists can support several National Patient Safety Goals.