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.

Search All Content

Clear all filter(s)

Clear all filter(s)

Displaying 1 - 20 of 3444 Results

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

Save to Library

Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.

Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.

Interventions to increase patient safety in long-term care facilities-umbrella review.

Save to Library

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.

Assessing experiences of racism among Black and White patients in the emergency department.

Save to Library

Agarwal AK, Sagan C, Gonzales R, et al. J Am Coll Emerg Physicians Open. 2022;3:e12870.

Black patients who report experiencing racism in healthcare report poorer quality of care. In this text-message based study, Black and White patients discharged from the emergency department (ED) were asked about their overall quality of care and whether they perceived an impact of their race on their care. While Black patients reported high overall quality of care, 10% believed their race negatively impacted their care. The authors highlight the importance of asking about the impact of race on care to identify and reduce potential disparities.

National Quality Forum. 2023 Annual Conference.

Save to Library

National Quality Forum. Omni Shoreham Hotel, Washington DC, February 20-22, 2023.

This hybrid annual conference will focus motivating innovation through effective measurement in health care. The content will be directed toward a multidisciplinary audience to support healthcare improvement in all communities in areas such as maternal outcomes and equity. The session will feature a presentation of the John Eisenberg award winners and Atul Gawande as a key note speaker.

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

Save to Library

Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.

Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing.

Save to Library

Baldwin CA, Hanrahan K, Edmonds SW, et al. Jt Comm J Qual Patient Saf. 2023;49:14-25.

Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 months: a randomized clinical trial.

Save to Library

Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.

Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram morphine equivalents (MME) up to 3 months following notification as compared to prescribers who are not notified. This article reports on the same cohort’s prescribing behavior at 4-12 months. Among prescribers who received notification, total weekly MME continued to decrease more than the control group during the 4-12 month period.

Quality and Safety in Health Care.

Save to Library

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.

The International Forum on Quality and Safety in Healthcare Europe.

Save to Library

Institute for Healthcare Improvement and British Medical Journal. Bella Center, Copenhagen, Denmark, May 15-17, 2023.

This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience supporting the theme of "Adapting to a changing world: equity, sustainability and wellbeing for all" will cover topics such as healthcare inequality, workforce wellbeing, and adverse events as learning opportunities.

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

Save to Library

Agency for Healthcare Research and Quality. January 24, 2023, 1:00 – 2:00 PM (eastern).

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session will introduce 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 will be shared.

The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review.

Save to Library

Thusini S’thembile, Milenova M, Nahabedian N, et al. BMC Health Serv Res. 2022;22:1492.

Health systems often consider return on investment (ROI) when considering implementation of quality improvement and patient safety interventions (i.e., costs saved by preventing medical errors or improving quality of care). This systematic review explored how ROI concepts have been used in studies assessing large-scale quality improvement programs.

Driving Learning and Improvement After RCA2 Event Reviews.

Save to Library

Collaborative for Accountability and Improvement. January 26, 2023, 2:00-3:00 PM (eastern).

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session will discuss challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.

International Society for Quality in Health Care Conference.

Save to Library

International Society for Quality in Health Care, Korean Society for Quality in Health Care, Health Insurance Review and Assessment Service, and the Korea Institute for Healthcare Accreditation, COEX Convention and Exhibition Center, Seoul, Republic of Korea, August 27-30, 2023.

This conference will explore the theme of “'Technology, Culture, and Coproduction: Looking to the Horizon of Quality and Safety” and will provide sessions on patient safety topics such as learning from mistakes, human factors and Safety II. The call for papers closes January 26, 2023.

Sources of nurse-sensitive inpatient safety improvement.

Save to Library

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.

Lessons learned in implementing a chronic opioid therapy management system.

Save to Library

Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

Save to Library

Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

Save to Library

Childs E, Tano CA, Mikosz CA, et al. Jt Comm J Qual Patient Saf. 2023;49:26-33.

In response to the increase in opioid deaths, the Centers for Disease Control and Prevention (CDC) released the Guidelines for Prescribing Opioids for Chronic Pain in 2016, with an update released in 2022. This study reports on the CDC Opioid QI Collaborative which was launched to identify successful evidence-based strategies for implementing the guidelines. The challenges and strategies described in the publication can be used by health systems to accelerate implementation of the guidelines.

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

Save to Library

Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.

Global Ministerial Summit on Patient Safety.

Save to Library

Federal Office of Public Health. 2m2c Convention Centre, Montreux, Switzerland, February 23-24, 2023.

Medical errors continue to cause harm worldwide despite the planning and efforts to reduce them. This bi-yearly session will feature topics exploring the theme of “Less Harm, Better Care – from Resolution to Implementation.” It will cover weaknesses in improvement initiative implementation surfaced by the COVID-19 pandemic and offer approaches for addressing unsustainable program launches and implementation practices.

Resilient Healthcare and the Safety-I and Safety-II Frameworks

Save to Library

Perspective on Safety December 14, 2022

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users