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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 35 Results
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.
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 January 16, 2024.
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

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.

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. 

Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

Katz MJ, Tamma PD, Cosgrove SE, et al. JAMA Netw Open. 2022;5(2):e220181.

Overuse of antibiotics has been common in nursing homes; therefore, antibiotic stewardship programs (ASPs) have been emphasized by experts. To assist facilities, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use developed programs and a toolkit to improve the appropriate use of antibiotics. This quality improvement program found that a focused educational initiative to establish ASPs in nursing homes was associated with reduction in antibiotic use in those facilities with high levels of engagement.

Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369.

This notice announces a call for comments on an information collection project drawing from the Comprehensive Unit-based Safety Program (CUSP). This project will support the implementation of targeted hospital-acquired infection improvement initiatives in intensive care units, long term care and surgical environments to reduce the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). The process for submitting comments is now closed.
Sterling RS, Berry SA, Herzke C, et al. Am J Med Qual. 2021;36:57-59.
The COVID-19 pandemic has necessitated rapid adjustments in hospital operations to address patient care demands. This commentary discusses how one hospital system utilized their quality and safety staff during the pandemic, and how that experience informed the responsiveness of system-wide quality improvement operations.
Patient Safety Primer September 7, 2019
Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.
Kronick R, Arnold S, Brady J. JAMA. 2016;316:489-90.
The publication of To Err Is Human in 1999 drew national attention to the issue of patient safety and is often credited with catalyzing widespread efforts to reduce health care–related harm. At the time of the report's publication, central line–associated bloodstream infections (CLABSIs) were considered unpreventable. However, subsequent public reporting programs and the trend toward nonpayment for preventable harm have led not only to a significant reduction in CLABSIs, but a decrease in other types of hospital-acquired conditions as well. This directly translates into improved patient outcomes and reduced health care costs. This commentary highlights progress made in patient safety and suggests that future efforts should focus on improving the measurement of adverse events and mitigating diagnostic error. A past PSNet perspective discussed the evolution of patient safety as it relates to surgery.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.
Needleman J, Pearson ML, Upenieks V, et al. Jt Comm J Qual Patient Saf. 2016;42:61-69.
This evaluation of the Transforming Care at the Bedside initiative—a collaborative intended to drive engagement of bedside nurses in enhancing safety through unit-based quality improvement projects—found highly positive perceptions of the program and evidence of widespread implementation of new innovations.
Hicks CW, Rosen MA, Hobson DB, et al. JAMA Surg. 2014;149:863-8.
Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.
Thom KA, Li S, Custer M, et al. Am J Infect Control. 2014;42:139-43.
Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and mortality. Efforts to combat these complications include implementation of checklists and—perhaps more importantly—the enhancement of safety culture. Despite the widespread success of these interventions, some institutions continue to experience CLABSI rates that are above national benchmarks. This study describes the introduction of a unit-based quality nurse dedicated to preventing CLABSIs within a surgical intensive care unit (ICU) at an academic medical center. The quality nurse helped to educate staff about health care–associated infections and prevention strategies. The nurse also provided immediate, direct feedback to staff regarding their compliance with best practices. The average CLABSI rate decreased significantly, even after adjusting for multiple factors including reduction in CLABSI rates in other adult ICUs. A unit-based quality nurse may prove to be a powerful adjunct to the current available tools for reducing these costly infections.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Jt Comm J Qual Patient Saf. 2013;39:396-403.
Leadership WalkRounds—derived from the business management approach of "management by walking around"—are being more widely used as a means of error detection and improving safety culture. This report from a children's hospital, in which structured walkrounds by nursing and physician leaders were implemented on six units, found that this approach increased staff engagement in safety efforts, identified hidden system flaws, and resulted in the successful implementation of multiple quality improvement projects. Although this study did not specifically measure the effect of walkrounds on safety climate, prior studies have found conflicting results, which might imply that different methods of performing walkrounds may influence their success.
Nedved P, Chaudhry R, Pilipczuk D, et al. J Nurs Adm. 2012;42:431-434.
A unit-based nurse patient safety officer was implemented on a surgical unit at an academic medical center that had a persistently high rate of falls. The fall rate among inpatients decreased markedly after the patient safety officer position was begun.