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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 1597 Results
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20:481-490.
… is lacking. For this pilot study of patients in a French nursing home , ADE risk scores were calculated before and six … medication and substantial cost savings for the nursing home, are reported in this preliminary assessment. … … and medication cost of the elderly people living in a nursing home: a before-after study [published online ahead of …
He M, Li Y, Fang F. J Am Med Dir Assoc. 2020;21:905-908.
… This study combined quality ratings from Nursing Home Compare with state-level data to examine the association between nursing home-reported quality and COVID-19 cases and deaths. After adjusting for nursing home size and the racial composition of the …
Browne J, Braden CJ. Am J Crit Care. 2020;29:182-191.
This study explored the relationship between nursing workload and turbulence, or unexpected work complexities and activities. Using responses from a survey of members of the American Association of Critical-Care Nurses, the authors identified several types of turbulence, such as changes in acuity, interruptions, distractions, lack of training, and administrative demands. They found that turbulence was strongly correlated with patient safety risk whereas workload had the weakest association. Acknowledging the difference between nursing workload and turbulence can enhance our ability to target resources in nursing care and improve patient outcomes.  
Rhudy LM, Johnson MR, Krecke CA, et al. Worldviews Evid Based Nurs. 2019;16:362-370.
Nursing handoffs at change of shift are critical for nurses to exchange information about patients; disruptions have been associated with adverse events.  After observing 100 nurse-to-nurse handoffs and conducting four focus groups, authors identified multiple sources of disruptions including those by patients and family members, which accounted for half the interruptions outside of the nurse handoff dyad.  Nurses identified some interruptions as valuable and relevant to patient care.
Castle NG, Handler S, Engberg J, et al. Health Care Manage Rev. 2007;32:66-76.
… Health Care Manage Rev … The researchers surveyed nursing home administrators and found that safety … care. … Castle NG, Handler S, Engberg J, Sonon K. Nursing home administrators' opinions of the resident safety culture in nursing homes.  Health Care Manage Rev . 2007;32(1):66-76. …
Patient Safety Primer September 7, 2019
… staffing structure. A related proposed pathway is missed nursing care. Missed nursing care is a subset of the category known as error of omission. It refers to needed nursing care that is delayed, partially completed, or not …
Brauner D, Werner RM, Shippee TP, et al. Health Aff (Millwood). 2018;37:1770-1778.
… … The Centers for Medicare and Medicaid Services launched Nursing Home Compare in 2002 to prompt public reporting on … the quality and safety of care provided in United States nursing homes . Researchers found that when comparing nursing homes' performance on a variety of Nursing Home …
Mody L, Greene T, Saint S, et al. Infect Control Hosp Epidemiol. 2017;38:287-293.
… Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for … developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion …
Castle NG, Wagner LM, Perera S, et al. J Patient Saf. 2010;64:59-67.
… to safety improvement activities. AHRQ developed the Nursing Home Survey on Patient Safety Culture to specifically assess safety climate in this setting, where nursing home residents are vulnerable to a host of safety … an overall poor level of safety culture in a sample of 40 nursing homes. Administrators and managers had a more …
Gandhi A, Yu H, Grabowski DC. Health Aff (Millwood). 2021;40:384-391.
… Prior research has found that high nursing staff turnover is associated with lower patient … Services (CMS) began collecting daily staffing data for US nursing homes and found that nurse turnover rates were … healthcare consumers and may incentive efforts to reduce nursing staff turnover. … Gandhi A, Yu H, Grabowski DC. …
Hughes CM, Lapane KL. Int J Qual Health Care. 2006;18:281-6.
… discovered a need to better address safety culture in nursing homes, drawing on findings from a self-reported … Investigators surveyed more than 360 nurses and 630 nursing assistants on different aspects of safety. These … that their modified tool wasn't designed specifically for nursing homes. This setting creates unique challenges but …