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 235 Results

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.

Using potentially preventable severe maternal morbidity to monitor hospital performance.

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Fridman M, Korst LM, Reynen DJ, et al. Jt Comm J Qual Patient Saf. 2023;49:129-137.

Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.

Patient Safety Concerns and the LGBTQ+ Population

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Perspective on Safety February 1, 2023

This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.

In Conversation with Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population

Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.

Sources of nurse-sensitive inpatient safety improvement.

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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.

Measuring Patient Safety

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Perspective on Safety December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Association of measured quality and future financial performance among hospitals performing cardiac surgery.

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Enumah SJ, Sundt TM, Chang DC. J Healthc Manag. 2022;67:367-379.

Hospitals that implement quality improvement initiatives improve patient safety but also incur financial expenses related to implementation, sustainment, and reporting. This study used data from the American Hospital Association and Hospital Compare to evaluate the relationship of financial performance and quality in hospitals performing cardiac surgery. The findings indicate hospitals with lower Patient Safety Indicator 90 (PSI 90) scores had poorer financial performance in the following year.

The impact of meaningful use and electronic health records on hospital patient safety.

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Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.

Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

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Adapa K, Ivester T, Shea CM, et al. Jt Comm J Qual Patient Saf. 2022;48:642-652.

Tiered huddle systems (THS) include staff at all levels of the organization- frontline healthcare workers, managers, directors, and executives- and have been shown to increase adverse event reporting and improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to increase event reporting. Based on an interrupted time series analysis, reporting increased for total safety events, including near misses.

Modes of failure in venous thromboembolism prophylaxis.

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Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.

Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).

The deterrent effect of tort law: evidence from medical malpractice reform.

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Zabinski Z, Black BS. J Health Econ. 2022;84:102638.

Tort reform and changes in medical malpractice liability can impact patient safety. This longitudinal analysis found that caps on noneconomic damages in medical malpractice lawsuits were associated with higher rates of preventable adverse events in hospitals.

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

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Waters TM, Burns N, Kaplan CM, et al. BMC Health Serv Res. 2022;22:958.

Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

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Locey KJ, Webb TA, Stein BD, et al. Jt Comm J Qual Patient Saf. 2022;48:403-410.

The AHRQ patient safety indicators (PSIs) are widely used measures of preventable complications and quality of care. This study found that a hospital’s internal policies about admission type introduces variation in PSI scores for elective surgeries.

Patient Safety Indicators Overview.

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Agency for Healthcare Research and Quality

The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective. Originally released in 2005, the PSI were most recently updated in July 2022.

Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.

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Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.

The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

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Bhakta S, Pollock BD, Erben YM, et al. J Hosp Med. 2022;17:350-357.

The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.

Association of measured quality with financial health among U.S. hospitals.

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Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.

While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.

The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE

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Patient Safety Innovation April 7, 2022

Venous thromboembolism (VTE) is a serious but preventable medical condition in which blood clots form in the veins.

Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance.

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Padula WV, Armstrong DG, Goldman DP. Mayo Clin Proc. 2022;97:221-224.

The complexities of the care environment are known contributors to harm and initiative failure. The authors suggest that systemic versus siloed approaches to patient harm reduction will reduce difficulty in accomplishing improvement.

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

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Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2022;57:654-667.

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.

Hospital Performance Report.

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Trenton, NJ: New Jersey Department of Health and Senior Services.

Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.

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