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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 1716 Results
Perspective on Safety April 24, 2024
… demand for qualified nurses has outpaced supply, causing nursing shortages, which were further exacerbated by the COVID-19 pandemic. 2 The nursing workforce has increased steadily since the 1970s. In … number had grown to 3.2 million. 3 Although this shows nursing is a growing profession, it has not been able to keep …
Katie Boston-Leary headshot

Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT, is the Director of Nursing Programs at the American Nurses Association and Adjunct Professor at the University of Maryland School of Nursing and the Frances Payne Bolton School of Nursing at Case Western Reserve University. We spoke to her about patient safety amid nursing workforce challenges.

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 …
Kathleen Sanford

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

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.

Joan Stanley

Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN).  We spoke to her about 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.

Sanghavi P, Pan S, Caudry D. Health Serv Res. 2020;55(2):201-210.
… Study … Health Serv Res … 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 …
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20(5):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 …
Havaei F, MacPhee M, Dahinten S. J Adv Nurs. 2019;75(10):2144-2155.
… Study … Journal of advanced nursing … J Adv Nurs … This study looked at the impact of two … care and adverse events. The authors found that the team nursing model reported higher frequency of adverse events …
Perspective on Safety August 1, 2012
… 1.5 million Americans reside in the nearly 16,000 nursing homes across the United States.( 1 ) In 2008, 2.8 … or 7.2% of the population aged 65 and older, had a nursing home stay.( 2 ) The nursing home setting provides a very complex set of …
An expert on patient safety in nursing homes, Dr. Castle is a Professor at the University of Pittsburgh in the Department of Health Policy and Management.
Perspective on Safety September 1, 2012
… The federal government has long been involved with the nursing profession, the largest component of the health care … shape the size, composition, and distribution of the nursing workforce, as well as help advance the scientific … the work of agencies such as the National Institute of Nursing Research, the Veterans Administration, and the Agency …
Prof. Needleman has performed some of the key studies on how the nursing workforce influences health outcomes, including seminal articles published in the New England Journal of Medicine in 2002 and 2011.
Perspective on Safety March 1, 2018
… findings remind us that errors of omission—such as missed nursing care—may be as important to patient safety as errors … have time to complete all necessary care, and this missed nursing care increases the risk of patients dying in the … mistakes being made, but also to maximize the capacity for nursing care and surveillance to be undertaken—to ensure the …
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
Patient Safety Primers
Patient Safety Primer September 7, 2019
… staffing structure. A related proposed pathway is missed nursing care (also described as "unfinished nursing care" and "care left undone"). Missed nursing care is a subset of the category known as error of …
Wang X, Wilson C, Holmes K. J Gerontol Soc Work. 2021:1-17.
… Study … J Gerontol Soc Work … Nursing home residents are especially vulnerable to COVID-19 … living conditions. Using publicly available data for nursing homes in Florida, this study explored the association between nursing home characteristics and COVID-19 cases and deaths. …
He M, Li Y, Fang F. J Am Med Dir Assoc. 2020;21(7):905-908.
… Med Dir Assoc … 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 …
Schuelke S, Aurit S, Connot N, et al. Nurs Adm Q. 2020;44(3):280-287.
… of a multi-site study examining the impact of a virtual nursing care team on missed nursing care . Findings indicate the missed care and reasons … research is necessary to explore the impact of virtual nursing. … Schuelke S,  Aurit S, Connot N, et al. The effect …
Browne J, Braden CJ. Am J Crit Care. 2020;29(3):182-191.
… J Crit Care … This study explored the relationship between nursing workload and turbulence, or unexpected work … weakest association. Acknowledging the difference between nursing workload and turbulence can enhance our ability to target resources in nursing care and improve patient outcomes.   … Browne J, …
Patient Safety Primer February 24, 2022
… care of older adults in Medicare and Medicaid certified nursing homes (NHs) associated with the COVID-19 pandemic, … 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes,” originally appearing in PSNet on April 21, … vaccines became available in December 2020 ( CMS COVID-19 Nursing Home Data website ). Various factors associated with …
WebM&M Case April 26, 2023
… (COPD), and known high risk for falling was admitted to a nursing home. During the first two months of her stay, she … of death was documented as hip trauma from the fall at the nursing home. … Case 2: … A 78-year-old woman with a history … anxiety, end-stage dementia, and falls was admitted to a nursing home. Two days after admission, she was seen by the …
Perspective on Safety March 16, 2020
… still need to be enhanced across the continuum of medical, nursing, and other clinical education — from undergraduate to … be linked to the initial education received by medical and nursing professionals . However, these efforts have not been … of education or across professions of medicine and nursing. Historically, the approach to medical and nursing