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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 40 Results

Diagnosis (Berl)2020;7(4):345-411.

COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.   

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   

Jt Comm J Qual Saf. 2020;46(7):PI-II:2020;371-399.

The Eisenberg Awards honor individuals and organizations who have had noteworthy impacts on patient safety and quality improvement. This article collection highlights the work of the 2019 honorees: Gordon D. Schiff, MD; WellSpan Health, York, Pennsylvania; and HCA Healthcare, Nashville, Tennessee.

Nicklin W, Hughes L, eds. Patient Safety. Healthc Q. 2020;22(Sp2):1-128.

Articles in this special issue report on initiatives undertaken by the Canadian National Patient Safety Consortium with a focus on the effect patient partnerships on initiative priority areas including never events, safety culture and homecare safety improvements.
Ann Intern Med. 2019;171(7_Suppl):s1-s82.
The States Targeting Reduction in Infections via Engagement (STRIVE) initiative was 3-year hospital-based program using a multimodal, evidence-based intervention targeted at reducing healthcare-associated infections (HAI) and strengthening state-hospital relationships to improve infection control efforts. The intervention recruited hospitals with a high burden of HAI; a total of 337 hospitals across 23 states and the District of Columbia participated in the program. The STRIVE intervention consistent of four components: (1) baseline assessment of each participating hospital conducted by a state partner, (2) tiered approach to HAI prevention, (3) educational content, and (4) on-site technical assistance. PubMed citations Central-line Associated Blood Stream Infection (CLABSI) Over the three-year study period, no substantial reduction in CLABSI rates were observed; unadjusted rates decreased from 0.88 to 0.80 infections per 1,000 catheter-days. The authors did observe reductions in central-line catheter use during the study period (24.05 to 22.07 central line-days per 100 patient-days); however, this trend was also documented in the pre-intervention period. Catheter-Associated Urinary Tract Infection (CAUTI) Baseline CAUTI rates at participating hospitals were low. Over the three-year study period, the unadjusted CAUTI rate decreased slightly; unadjusted rates decreased from 1.12 to 1.04 infections per 1,000 catheter-days. Unadjusted urinary catheter use decreased from 21.46 to 19.83 catheter-days per 100 patient-days. Clostridioides Difficile Infection (CDI) The authors observed a statistically significant reduction in Clostridioides difficile infection (CDI) over the three-year period, from 7.0 cases days to 5.7 cases per 10,000 patient-days. However, these decreases mirrored national trends in CDI reduction and are likely attributed to recent emphasis on CDI clinical guidelines, mandated CDI reporting, and the inclusion in value-based purchasing, rather than the STRIVE intervention. Methicillin-Resistant Staphylococcus Aureus (MRSA) Infection. Baseline MRSA rates at participating hospitals were low. Over the three-year period, the unadjusted MRSA rate decreased slightly from 0.075 to 0.071 cases per 1,000 patient-days. State Partner Relationships and HAI Prevention Efforts While STRIVE did not result in quantitative improvements in CAUDI, CLABSI, CDI or MRSA rates, the initiative did strengthen relationships between hospitals and state health departments. Through the baseline assessment, state partners were able to identify gaps in HAI prevention efforts and opportunities to improve partner-hospital relationships. State partners also reported improvements in hospital-level prevention activities over the three-year period, as well as improvements to state partner-hospital relationships.
Woeltje KF, Olenski LK, Donatelli M, et al. Joint Commission journal on quality and patient safety. 2019;45:480-486.
The Eisenberg Award honors individuals and organizations who have made important contributions to patient safety and quality improvement. Spotlighting the accomplishments of the 2018 recipients, this special issue includes an interview with Dr. Brent C. James, as well as articles on programs at The Society of Thoracic Surgeons and BJC HealthCare.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Jt Comm J Qual Patient Saf. 2016;42(6):243-264.

The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving quality and patient safety. This special collection of articles provides insights on the work of the 2015 honorees: Pascale Carayon, PhD; Premier, Inc.; and Mayo Clinic Hospital-Rochester.

Alverzo JP. (ed). Rehabil Nurs. Jan-Feb 2016;41(1):1-59.

Safety challenges in residential care facilities are well documented. Articles in this special issue explore falls in rehabilitation settings, including nurses' role in managing fall risks and strategies to prevent falls.

Allen G, ed. AORN J. 2015;101:505-596.

A primary concern in the perioperative setting is the prevention of health care–associated infections, particularly surgical site infections. Articles in this special issue explore strategies to reduce risk of infection in the perioperative environment, with discussions focusing on human factors principles, instrument sterilization, and specimen management.
Jt Comm J Qual Patient Saf. 2015;41:195-211.
Articles in this special issue highlight the achievements of the 2014 John M. Eisenberg Patient Safety and Quality Award honorees. The awards recognize a leader in diagnostic error prevention, a program designed to collect national data on the quality and safety of surgical care, and a system-level effort to reduce sepsis mortality.

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.

This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-S141.

Articles in this special issue explore evidence developed from an AHRQ-funded initiative to reduce health care–associated infections (HAIs). Researchers examine epidemiological issues, disparities in HAI rates, quality improvement efforts, assessment tools, and how antibiotic stewardship programs influence HAI prevention and research.
Hamilton DK, Stichler JF, eds. HERD. 2013;7(suppl):1-154.
Articles in this special supplement draw from AHRQ-funded efforts to reveal how designing around space and human factors can reduce the spread of health care–associated infections. Design interventions described include air filtration systems, decontamination of water sources, and antimicrobial surfaces.

Martin RF, Sanchez JA, eds. Surg Clin North Am. 2012;92(1):1-177. 

This special issue includes articles exploring systems-oriented safety improvement in surgical care.
Bagian JP. Human Factors and Ergonomics in Manufacturing & Service Industries. 2011;22.
Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.