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 458 Results

Underreporting of quality measures and associated facility characteristics and racial disparities in US nursing home ratings.

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Sanghavi P, Chen Z. JAMA Netw Open. 2023;6:e2314822.

Underreporting patient safety events can hinder opportunities for improvement. Building on previous research, this study examined the association between nursing home characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury and pressure ulcers). Findings suggest underreporting of both measures, and researchers identified an association between underreporting and the racial and ethnic composition of the nursing home facility.

Strategies to Improve Organizational Health Literacy.

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Patient Safety Primer May 31, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health systems easier to navigate and health information easier to understand, improving healthcare delivery and outcomes.

Personal Health Literacy

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Patient Safety Primer May 30, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports.

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Kepner S, Bingman C, Jones RM. Patient Saf. 2023;Epub Apr 28.

Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.

Lessons from the Covid War: An Investigative Report.

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Covid Crisis Group. New York: Public Affairs; 2023. ISBN‏: ‎9781541703803.

The transfer of failure experiences to generate learning and improve service is a complicated responsibility. This book examines breakdowns in the US response to the COVID-19 epidemic to understand causes of the problems, in order to better prepare health care, government, and public health systems for future pandemics. It also discusses what successes were achieved and how to capitalize on those improvements.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2023.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2022 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional sections cover educational, publication, and learning management system efforts.

Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.

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WebM&M Case April 26, 2023

This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.

Patient Safety Indicators.

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Patient Safety Primer April 26, 2023

Patient safety indicators are tools used to assess the frequency, severity, and impact of potential harms in health care, both within health care organizations and at the health care system, regional, and national levels. This primer describes how patient safety indicators are applied in acute, ambulatory, and post-acute care settings and how these indicators are being incorporated into new federal healthcare quality measurement initiatives.

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

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Keers RN, Wainwright V, McFadzean J, et al. PLOS One. 2023;18:e0282021.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Efforts to improve the safety culture of the elderly in nursing homes: a qualitative study.

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Indarwati R, Efendi F, Fauziningtyas R, et al. Risk Manag Healthc Policy. 2023;16:393-400.

Promoting a culture of safety has been identified as an intervention to improve patient safety in long term care. In this study, focus groups with nursing, social work, and support staff were conducted to determine how the safety culture could be improved in four long term care facilities in Indonesia. Proposed interventions include new hire orientation, training, improvement in facility design, and increased security staff.

Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt.

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Hopkins E, Kohler J. ProPublica. April 3, 2023.

Systemic bureaucracy can contribute to process gaps that result in needless complexities and failure. This news story outlines how inefficiencies in disciplinary investigations can enable clinicians with poor and questionable care records to practice over time.

Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic.

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Evans ME, Simbartl LA, Kralovic SM, et al. Infect Control Hosp Epidemiol. 2023;44:420-426.

Healthcare-associated infections (HAIs) are among the most common complications of hospital or long-term care stays. HAI data reported to the Veterans Affairs centralized database was analyzed to determine rates of several HAIs, both before and during the pandemic, to assess changes. Rates were variable in acute care and no changes were seen in long-term care.

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

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Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.

Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

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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.

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.

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Engle RL, Gillespie C, Clark VA, et al. J Gerontol Nurs. 2023;49:13-17.

Nurses’ willingness to speak up about resident safety concerns varies based on anticipated leadership response and support. Clinical and non-clinical staff at six Department of Veterans Affairs (VA) nursing homes with diverse safety climate ratings (high, medium, low) were interviewed to understand the association between resident safety and safety climate. Staff at high safety climate facilities described open communication and leadership responsiveness as contributors to a strong safety climate and willingness to speak up.

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

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Agency for Healthcare Research and Quality. January 24, 2023.

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session introduced the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey were shared.

AHRQ Safety Program for MRSA Prevention.

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Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023.

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. This project will support the implementation of targeted hospital-acquired infection prevention initiatives building on the Comprehensive Unit-based Safety Program (CUSP) concept. The cohort that is focused on long-term care is currently recruiting participants.

National patient safety goal to improve health care equity.

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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.

Surveys on Patient Safety Culture Nursing Home Survey: 2023 User Database Report.

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Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Publication No. 23-0018.

The AHRQ Surveys on Patient Safety Culture™(SOPS®) Nursing Home Survey assesses safety culture and resident safety in nursing homes. This report summarizes survey data from 3,224 staff working in 62 nursing homes. Respondents reported positive perceptions about both resident safety overall and feedback and communication regarding safety incidents. Areas for improvement included sufficient staffing to handle the workload and maintain resident safety.

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