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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 2928 Results
Perspective on Safety August 30, 2023
… What Is Virtual Nursing? … As with distance learning and remote work, … these rapid, ad hoc implementations of telehealth, virtual nursing is part of a tested model of healthcare that predates … planning could help prevent such gaps. 1,2 … Virtual Nursing and the Nursing Workforce … The National Academies of …

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

Kathleen Sanford

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Perspective on Safety November 27, 2023
… the classroom and clinical settings of these baccalaureate nursing programs, students acquire the knowledge, skills, and … the standards, curricula, and execution of undergraduate nursing education must be of high quality and include a particular focus on safety topics. … Nursing Curricula … Several organizations have published …

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
… study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for …
Sanghavi P, Pan S, Caudry D. Health Serv Res. 2020;55:201-210.
Nursing Home Compare publicly available reports on the quality and safety of care provided by nursing homes in the United States. Prior research has found that Nursing Home Compare does not accurately capture patient safety performance. This study compared falls with injury data self-reported by nursing homes against those identified in Medicare claims data and found that falls with injury were substantially underreported by nursing homes, indicating that that the data used by Nursing Home Compare may be inaccurate.
Havaei F, MacPhee M, Dahinten S. J Adv Nurs. 2019;75:2144-2155.
This study looked at the impact of two different models of delivering care by nurses, team versus total care, on quality of care and adverse events. The authors found that the team nursing model reported higher frequency of adverse events when there were licensed practical nurses on the team.

Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320.

Research provides evidence that sleep deprivation among nurses is a threat to patient safety. Using observational data, this study assessed the association between sleep duration among nurses and patient safety. On average, nurses reported less than 7 hours of sleep before a shift. Less sleep was associated with lower ratings on patient safety culture measures.
Monsees E, Goldman J, Vogelsmeier A, et al. Am J Infect Control. 2020.
There is a scarcity of literature on the role nurses play in antibiotic stewardship (AS). This article describes the results of a multisite survey of nurse perceptions of AS practices. Statistical analyses of 558 survey responses indicate that nurses identify with their role in AS processes but believe hospital safety culture inhibits their work in this area.
Vos J, Franklin BD, Chumbley G, et al. Int J Nurs Stud. 2019;102.
Little is known about deviations from best practices in administration of intravenous infusions that occur as a result of nurses’ clinical judgement. This study explored the ways nurses contribute to system-level resilience in relation to infusion safety. Secondary analysis of qualitative data on errors and policy deviations in intravenous infusion administration in 16 English hospitals suggest that nurses are a key source of system-level resilience.
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20:481-490.
The value of medication reviews in reducing adverse drug events (ADEs) is now generally accepted although robust evidence of cost or clinical effectiveness of such reviews is lacking. For this pilot study of patients in a French nursing home, ADE risk scores were calculated before and six months after a pharmacist-led multidisciplinary review of each patient’s medications. Significant drops in ADE risk scores, as well as reductions in the number of patients taking at least one potentially inappropriate medication and substantial cost savings for the nursing home, are reported in this preliminary assessment.
Aiken LH, Cimiotti JP, Sloane DM, et al. Med Care. 2011;49:1047-53.
The association between lower patient-to-nurse ratios and inpatient mortality has been demonstrated in classic studies, providing an impetus for laws in 15 states that mandate the maximum number of patients per nurse. This study explores the mechanism by which reducing patient-to-nurse ratios improves outcomes. Using a large database of patient discharges and nurse surveys from 665 hospitals in 4 states, the authors found that decreasing the number of patients per nurse improved mortality and failure to rescue predominantly in hospitals rated as having a good work environment. Hospitals with a poor work environment derived no benefit from reducing patient-to-nurse ratios. The critical role that nurses play in ensuring patient safety is discussed further in this Patient Safety Primer.
Hughes C, Lapane KL. Int J Qual Health Care. 2006;18:281-6.
This Agency for Healthcare Research and Quality (AHRQ)–supported study discovered a need to better address safety culture in nursing homes, drawing on findings from a self-reported survey. Investigators surveyed more than 360 nurses and 630 nursing assistants on different aspects of safety. These included overall safety perception, teamwork within units, communication, actions promoting safety, and support for patient safety. Although the findings suggest areas for improvement, the authors appropriately point out that their modified tool wasn't designed specifically for nursing homes. This setting creates unique challenges but also affects elderly patients who tend to be at higher risk for adverse events, making safety initiatives critical.