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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 18382 Results
Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.
Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.
Jones BE, Sarvet AL, Ying J, et al. JAMA Netw Open. 2023;6:e2314185.
Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.
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. 
Institute for Safe Medication Practices.
The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety.  The 2023 nomination process is open through August 6, 2023. 
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

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.

Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

Manadan A, Arora S, Whittier M, et al. Am J Med Open. 2023;9:100028.
The ”weekend effect” refers to worse outcomes among patients admitted on the weekend versus weekday. Based on a sample of over 121 million adult hospital discharges from 2016 to 2019, researchers examined the association between several different variables and in-hospital death. Multivariable analyses identified several predictors of in-hospital death (e.g., older age, higher number of comorbidities, etc.) and the researchers found that patients admitted on weekends underwent fewer procedures and had higher mortality rates compared to patients admitted on weekdays. The authors suggest that improved staffing and availability of procedures may improve mortality.
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;Epub May 17.
Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.
Ross P, Hodgson CL, Ilic D, et al. Contemp Nurse. 2023;Epub May 8.
Improved nurse staffing ratios and nursing skill mix have been linked to improved safety outcomes. This retrospective cohort study of over 13,000 patients admitted to a tertiary intensive care unit (ICU) in Australia between 2016 and 2020 found that a great concentration of critical care registered nurses (CCRNs) was associated with a lower risk of adverse events.

Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.
Barnett ML, Meara E, Lewinson T, et al. New Engl J Med. 2023;388:1779-1789.
Best practices for treating patients with opioid use disorder (OUD) include prescribing medications to treat OUD (naltrexone, naloxone, or buprenorphine) and limiting prescriptions of high-risk medications (opioid analgesics and benzodiazepines). This study of more than 23,000 patients with an index event related to OUD sought to determine racial and ethnic differences in safe prescribing. White patients were significantly more likely to receive buprenorphine and less likely to receive high-risk medications than Black or Hispanic patients in the 180 days after the index event. This difference persisted over the four-year study period.
Cox GR, Starr LM. J Healthc Manag. 2023;68:151-157.
Becoming a high-reliability organization (HRO) to improve patient safety is a goal of the Veterans Heath Administration (VHA). This commentary describes the VHA's implementation strategy and progress since 2019 at the patient, employee, and organizational levels. The three pillars of the VHA's HRO strategy are leadership commitment, a culture of safety, and continuous process improvement. Challenges associated with the COVID-19 pandemic are also discussed.
Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Gefter WB, Hatabu H. Chest. 2023;163:634-649.
Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.
Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 22.
The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).
Dietl JE, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2023;20:5698.
Miscommunication between healthcare providers can contribute to adverse events, but communication may be improved by strengthening psychological safety. This paper describes two studies on the association of communication, patient safety threats, and higher quality care and the mediating effect of psychological safety in obstetrical care. Results suggest psychological safety mediates the association of communication with quality of care and patient safety.
Yanni E, Calaman S, Wiener E, et al. J Healthc Qual. 2023;45:140-147.
I-PASS is a structured handoff tool that aims to improve communication and reduce adverse events during transitions of care. This article describes the implementation of a modified I-PASS tool for use in the emergency department (ED I-PASS) to improve transitions of care between pediatric emergency medicine physicians. Implementation of ED I-PASS decreased the perceived loss of key patient information during transitions of care (from 75% to 37.5%).