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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 777 Results
Schrimpff C, Link E, Fisse T, et al. Patient Educ Couns. 2023;110:107675.
Trust between patients and providers is essential to safe, effective healthcare. This survey of German patients undergoing implant surgeries (e.g., hip and knee replacements, dental implants, cochlear implants) found that adverse events negatively impact patient trust in their physicians, but effective patient-provider communication can mitigate the impacts.
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.

Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.

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. 
Farzandipour M, Nabovati E, Sharif R. J Telemed Telecare. 2023;Epub Jan 23.
Remote triage allows patients to receive guidance about whether to seek care and, if required, what level of care. This review of remote triage focuses exclusively on tele-triage studies conducted during the COVID-19 pandemic. The studies reported on five broad outcome categories (access to care, triage rates, patient safety, post-triage clinical outcomes, and patient satisfaction) with highly positive outcomes.
Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.
Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.
WebM&M Case February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures.

Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.
Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.
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.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
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.
Hunt J, Gammon J, Williams S, et al. BMC Health Serv Res. 2022;22:1446.
Isolation for infection prevention and control may result in unintended consequences for patient safety. Using focus groups at two hospitals, this study explored healthcare staff understanding of infection prevention practices and patient safety culture within insolation settings. Thematic analysis highlights the importance of engaged leadership, appropriate staffing, teamwork, and prioritization of patient-centered care in achieving a culture of safety and improvements in infection prevention.
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Boamah SA, Hamadi HY, Spaulding AC. J Patient Saf. 2022;18:e1090-e1095.
Medicare’s Hospital-Acquired Condition (HAC) Reduction Program financially incentivizes hospitals to reduce HAC rates and earlier research has shown hospitals in more diverse areas have higher odds of performing poorly. This study compares HAC reduction in Magnet and non-Magnet hospitals and examines potential racial and ethnic disparities. Similar to an earlier study, Magnet hospitals had significant improvements in methicillin-resistant Staphylococcus aureus (MRSA) rates, but not other HACs.

Washington, DC: United States Government Accountability Office; Publication GAO-22-105133. September 14, 2022.

COVID-19 generated unprecedented challenges for the nursing home industry, revealing and amplifying process, staffing, trust, and infection control weaknesses to the detriment of care. This report analyzed current infection protection actions in long-term care. A primary improvement conclusion drawn from the examination is to strengthen the role of infection control professionals.
Martins MS, Lourenção DC de A, Pimentel RR da S, et al. BMJ Open. 2022;12:e060182.
In early 2020, hospitals, organizations, and expert panels released recommendations to maintain patient safety while reducing spread of COVID-19. This review summarized safety recommendations from 125 studies, reviews, and expert consensus documents. Recommendations were categorized into one of four areas: organization of health services, management of airways, sanitary and hygiene measures, and management of communication. Planning and implementing best practices based on these recommendations ensure safe care during COVID-19 and future pandemics.
WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.
The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.
Soto C, Dixon-Woods M, Tarrant C. Arch Dis Child. 2022;107:1038-1042.
Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.