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 806 Results

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure.

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Hald EJ, Gillespie A, Reader TW. J Contingencies Crisis Manage. 2023;31:752-766.

Including both patient/relative and staff perspectives in investigations provides a deeper understanding of the event. This study applies natural language processing methodology to 40 staff and 53 patient/relative witness statements into a C. difficile outbreak in a UK trust. This novel method revealed that staff identified a lack of training and understaffing, whereas patients/relatives identified communication failures and the physical environment as contributing factors.

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: a NBSIs frontline ownership intervention.

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Mudrik-Zohar H, Chowers M, Temkin E, et al. Infect Control Hosp Epidemiol. 2023;44:1562-1568.

Nosocomial infections remain a persistent patient safety issue and can lead to serious patient harm. This article describes one Israeli hospital’s experience using department-level investigations to reduce the incidence of nosocomial bloodstream infections. Study findings demonstrated that department-level investigations coupled with increased staff awareness led to significant reductions in nosocomial bloodstream infections.

Impact of hospital-acquired pneumonia on the Medicare program.

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Baker DL, Giuliano KK, Desmarais M, et al. Infect Control Hosp Epidemiol. 2023;Epub Oct 25.

Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the United States. In this case-control retrospective study of Medicare beneficiaries, patients with HAP were 2.8 times more likely to die than patients without HAP. Length of stay and overall cost were also significantly higher in the HAP group. The authors suggest quality improvement efforts like the Keystone ICU project could decrease HAP rates, saving lives and money.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available.

Voices from frontline nurses on care quality and patient safety during COVID-19: an application of the Donabedian Model.

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Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.

The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

The influence of hospital leadership support on burnout, psychological safety, and safety climate for US infection preventionists during the coronavirus disease 2019 (COVID-19) pandemic.

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Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.

Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.

Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study.

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San José-Saras D, Vicente-Guijarro J, Sousa P, et al. BMC Med. 2023;21:312.

Inappropriate care, such as under- or over-treatment or unnecessary hospitalizations, can place patients at risk for adverse events. This observational study set in a high-complexity hospital in Spain found that patients with inappropriate hospital admissions (IHA) have a higher risk of subsequent adverse events, contributing to longer stays and additional costs.

Compliance with central line maintenance bundle and infection rates.

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Tripathi S, McGarvey J, Lee K, et al. Pediatrics. 2023;152:e2022059688.

Reducing central line-associated bloodstream infections (CLABSI) is an important patient safety improvement target. This study examined the relationship between compliance with evidence-based CLABSI guideline bundles and CLABSI rates in 159 hospitals. Between 2011 and 2021, researchers found that adherence to bundle guidelines was associated with a significant reduction in CLABSI rate.

Healthcare-associated infections in adult intensive care units: a multisource study examining nurses' safety attitudes, quality of care, missed care, and nurse staffing.

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Alanazi FK, Lapkin S, Molloy L, et al. Intensive Crit Care Nurs. 2023;78:103480.

Safety culture, nurses' safety attitudes, and staffing ratios have been shown to impact fall rates and other healthcare associated events. This study assessed if healthcare-associated infections (HAIs) could be associated with nurses' safety attitudes and other quality and safety metrics in the intensive care unit (ICU). Increased job satisfaction was associated with lower rates of HAI, as were lower rates of missed care. The study also found nurses' perceptions and actual incidence of two HAI were positively correlated, suggesting nurses can provide valuable information on HAIs and HAI reduction efforts.

Staying safe while getting well.

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Salamon M. Harvard Women's Health Watch. August 1, 2023

Patients can help minimize the potential for adverse events while in the hospital. Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect against mistakes causing harm.

Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic.

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Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.

The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.

Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort.

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Lyren A, Haines E, Fanta M, et al. BMJ Qual Saf. 2023;Epub Jul 17.

Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.

Quality and Safety in Health Care.

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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, six sigma, and high reliability organizations.

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

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Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).

Accuracy of infection reporting in US nursing home ratings.

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Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.

Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.

Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals.

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Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.

Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.

The spectrum of hospitalization-associated harm in the elderly.

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Schattner A. Eur J Intern Med. 2023;115:29-33.

Older patients are particularly vulnerable to harm during hospitalization. This article summarizes potential patient harm that can occur during hospitalization for older adults, including unnecessary testing or procedures, nosocomial infections, medical errors, falls, functional or cognitive decline, and post-discharge adverse events.

Preventing surgical site infections: implementing strategies throughout the perioperative continuum.

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Rosa R, Sposato K, Abbo LM. AORN J. 2023;117:300-311.

Preventing surgical site infections remains a persistent challenge to patient safety. This article outlines strategies to prevent surgical site infections during the perioperative period and the roles that infection surveillance, infection prevention bundles, and a culture of safety play a substantial role in decreasing the rate of surgical site infections.

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

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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.

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