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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 362 Results
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Subbe CP, Hughes DA, Lewis S, et al. BMJ Open. 2023;13:e065819.
Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held July 18, 2023.
Dresser S, Teel C, Peltzer J. Int J Nurs Stud. 2023;139:104436.
Understanding how nurses use their clinical judgment in activating early warning systems or rapid response teams is important in improving response to deteriorating patients. Interviews with 20 nurses revealed an overarching sense of responsibility to their patients, eight subthemes including experience, making sense of the data, and a culture of teamwork.
Mikhail J, King L. J Patient Saf. 2023;19:99-109.
Early recognition of warning signs of deterioration is key to activating the rapid response system (RRS) and prevention of serious adverse events. This review sought to understand how preparedness of ward-based nurses supports recognition of early warning signs and activation of RRS. Themes include knowledge of criteria to activate the RRS and deference to organizational hierarchy.
Olsen SL, Nedrebø BS, Strand K, et al. BMC Health Serv Res. 2023;23:179.
Regular monitoring of vital signs is key to early identification of patient deterioration and provision of rapid response. This hospital in Norway determined inconsistent documentation of vital signs could be a barrier to successful implementation of a rapid response system (RRS). During the decade following introduction and refinement of the RRS, the number of completed vital sign sets increased, as did intensive care consultation, another component of RRS. Overall the RSS was associated with a reduction of in-hospital and 30-day mortality rates.
Raff L, Moore C, Raff E. Hosp Pract (1995). 2023;51:29-34.
Language barriers can lead to diminished care and threaten patient safety. This retrospective study included patients with rapid response team (RRT) activation and compared disease severity and outcomes for patients whose primary language was Spanish versus English. Findings suggest that language barriers may contribute to delays in RRT activation and delays in care.

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. 
WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

Cresham Fox S, Taylor N, Marufu TC, et al. Intensive Crit Care Nurs. 2023;2023:103363.
While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.
Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.
Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.
Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.
Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Shiell A, Fry M, Elliott D, et al. Intensive Crit Care Nurs. 2022;73:103294.
Rapid response team (RRT) activations bring together a team of providers to immediately assess and treat a patient who is rapidly deteriorating. This mixed-methods study examined the characteristics of a collaborative RRT model in one Australian tertiary care hospital. The majority of activations occurred in general medicine units and some patients (approximately 5%) had more than five activations. Qualitative interviews with nurses and physicians highlighted how the collaborative RRT model improves patient safety and optimized early detection and management of patient deterioration.
Factora F, Maheshwari K, Khanna S, et al. Anesth Analg. 2022;135:595-604.
Rapid response teams (RRT) are designed to intervene at the earliest signs of clinical deterioration to prevent intensive care unit transfer, cardiac arrest, or death. This study presents the changes of in-hospital mortality rates following implementation of RRT, introduction of anesthesiologist-led RRT, and other policy changes. Results indicate a gradual decline of in-hospital mortality in the nine-year period following RRT introduction.
Thiele L, Flabouris A, Thompson C. PLoS ONE. 2022;17:e0269921.
Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.
Stevens JP. UpToDate. August 15, 2022.
Although rapid response programs have been advocated as promising patient safety strategies, the evidence regarding their benefits is mixed. This review provides an overview of rapid response systems, including key components and goals of the intervention. Further research is needed to provide justification on their use for adult patients.
McDade JE, Olszewski AE, Qu P, et al. Front Pediatr. 2022;10:872060.
Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.