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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 808 Results
International Association of Risk Management in Medicine. March 16-17, 2024, The University of Tokyo, Medical Campus.
This conference -- to be presented in tandem with the 11th World Congress on Clinical Safety--will provide oral and poster presentations related to the theme of "Journey to the New World of Healthcare Safety". Topics to be covered include infection control, psychological safety and healthcare worker safety. A post-conference on-demand viewing option will be available.

Sepsis Alliance. December 14, 2023, 12:00 - 3:30 PM (eastern). 

Healthcare-associated infections (HAIs) are a pervasive and preventable contributor to sepsis and patient harm. This session will discuss areas of focus in the HAI spectrum such as central line–associated bloodstream infections, or CLABSIs. The presenters will review prevention strategies and documentation to support their use in the care environment.
Atlanta, GA: Centers for Disease Control and Prevention; November 2023.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2022 revealed decreases in central line–associated bloodstream infections and other hospital-acquired infections while reporting little progress in other healthcare settings. The current report includes data from the National Healthcare Safety Network (NHSN).
Hald EJ, Gillespie A, Reader TW. J Contingencies Crisis Manage. 2023;31:752-766.
Including both patient/relative and staff perspectives in investigations provides a deeper understanding of the event. This study applies natural language processing methodology to 40 staff and 53 patient/relative witness statements into a C. difficile outbreak in a UK trust. This novel method revealed that staff identified a lack of training and understaffing, whereas patients/relatives identified communication failures and the physical environment as contributing factors.
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.
Baker DL, Giuliano KK, Desmarais M, et al. Infect Control Hosp Epidemiol. 2023;Epub Oct 25.
Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the United States. In this case-control retrospective study of Medicare beneficiaries, patients with HAP were 2.8 times more likely to die than patients without HAP. Length of stay and overall cost were also significantly higher in the HAP group. The authors suggest quality improvement efforts like the Keystone ICU project could decrease HAP rates, saving lives and money.

Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available. 
Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.
The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
San José-Saras D, Vicente-Guijarro J, Sousa P, et al. BMC Med. 2023;21:312.
Inappropriate care, such as under- or over-treatment or unnecessary hospitalizations, can place patients at risk for adverse events. This observational study set in a high-complexity hospital in Spain found that patients with inappropriate hospital admissions (IHA) have a higher risk of subsequent adverse events, contributing to longer stays and additional costs.
Tripathi S, McGarvey J, Lee K, et al. Pediatrics. 2023;152:e2022059688.
Reducing central line-associated bloodstream infections (CLABSI) is an important patient safety improvement target. This study examined the relationship between compliance with evidence-based CLABSI guideline bundles and CLABSI rates in 159 hospitals. Between 2011 and 2021, researchers found that adherence to bundle guidelines was associated with a significant reduction in CLABSI rate.
Alanazi FK, Lapkin S, Molloy L, et al. Intensive Crit Care Nurs. 2023;78:103480.
Safety culture, nurses' safety attitudes, and staffing ratios have been shown to impact fall rates and other healthcare associated events. This study assessed if healthcare-associated infections (HAIs) could be associated with nurses' safety attitudes and other quality and safety metrics in the intensive care unit (ICU). Increased job satisfaction was associated with lower rates of HAI, as were lower rates of missed care. The study also found nurses' perceptions and actual incidence of two HAI were positively correlated, suggesting nurses can provide valuable information on HAIs and HAI reduction efforts.

Salamon M. Harvard Women's Health Watch. August 1, 2023

Patients can help minimize the potential for adverse events while in the hospital. Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect against mistakes causing harm.
Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.
The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.
Lyren A, Haines E, Fanta M, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.

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, six sigma, and high reliability organizations.

Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series.  Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).
Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.
Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.