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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 179 Results
Global Sepsis Alliance.
… This website provides resources to raise awareness of sepsis, including information about its increasing incidence and causes for its delayed diagnosis . World Sepsis Day occurs yearly on September 13th. … Global Sepsis Alliance. …
Sepsis Alliance.
… Revealing incidents in which diagnostic delay led to sepsis , this video provides information to help consumers recognize the condition. … Sepsis Alliance. …
Massachusetts Sepsis Consortium.
Delayed diagnosis of sepsis is a primary patient safety concern. This campaign raises awareness of the symptoms of sepsis to engage patients in timely diagnosis and safe treatment of the condition. 
WebM&M Case June 1, 2019
Transferred to the emergency department from the transfusion center after becoming unresponsive and hypotensive, an elderly man with signs of sepsis is given incomplete and delayed antimicrobial coverage due to a history of penicillin allergy. Neither gram-negative nor anaerobic coverage were provided until several hours later, and the patient developed septic shock.
Vidrine R, Zackoff M, Paff Z, et al. Jt Comm J Qual Patient Saf. 2020;46:299-307.
Early recognition and treatment of sepsis is a critical safety issue. The authors of this study aimed to reduce the frequency of delayed sepsis recognition in a pediatric intensive care unit (PICU) through the use of an automated clinical decision support tool (CDS) prompting multidisciplinary sepsis huddles. After a two-year period, the average number of days between episodes of delayed sepsis recognition improved from one episode every 9 days to one every 28 days, and the median time to antibiotics decreased from 1.53 hours to 1.05 hours, representing a significant reduction.
Sreeramoju P, Voy-Hatter K, White C, et al. BMJ Open Qual. 2021;10:e001189.
… infections (HAIs) and community-acquired sepsis can result in significant patient harm. This article … a hospital-wide initiate to reduce HAIs and improve sepsis care.  Key components of the initiative included an … and clinician engagement, implementation of HAI and sepsis bundles, electronic health record-based clinical …
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:479-488.
… Missed or delayed diagnosis of sepsis can lead to serious patient harm. This study used a … analysis to measure potential misdiagnosis of sepsis in patients discharged from the emergency department … status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period following the ED …
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2016;42:122-138.
… Jt Comm J Qual Patient Saf … Early recognition of sepsis is a patient safety issue, due to the time-sensitive … and Medicaid Services–funded initiative to improve sepsis management in 15 facilities in Texas. Components … protocol (like a rapid response team ) for possible sepsis, and conducting audit and feedback for participating …
Amland RC, Hahn-Cover KE.  Am J Med Qual. 2016;31:103-10.
… Am J Med Qual … Sepsis is a clinical condition that can be rapidly fatal, … computerized decision support system aimed at identifying sepsis in patients before infection was suspected. … Amland … KE. Clinical Decision Support for Early Recognition of Sepsis.  Am J Med Qual . 2016;31(2):103-110. …
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-91.
… Saf … A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized … describes common errors in the early management of sepsis. … Jones SL, Ashton CM, Kiehne L, et al. Reductions in …
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
… this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look … emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations. … Nassery N, Horberg MA, Rubenstein …
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.
Barbash IJ, Kahn JM. J Crit Care. 2019;54:88-93.
… impact of the policies that require hospitals to engage in sepsis quality improvement on safety net hospitals. The 703 … with health systems. The authors concluded existing sepsis policies may harm safety-net hospitals and widen health disparities. … Barbash IJ, Kahn JM. Sepsis quality in safety-net hospitals: An analysis of …
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174:927-935.
… has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle ( SEP-1 ). This study examined sepsis patient encounters at one health system two years … clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). Ann Intern Med. Epub 2021 …
Kaya GK. Appl Ergon. 2021;94:103408.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).
Rhee C, Dantes R, Epstein L, et al. JAMA. 2017;318:1241-1249.
Early identification of sepsis is essential for initiating appropriate treatment and preventing mortality. In this retrospective study, researchers used clinical data to estimate the incidence of sepsis over time at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis remained stable during this time. Although inpatient mortality due to sepsis declined somewhat, there was no change in the combined outcome of death or discharge to hospice. In contrast, analysis of claims-based data suggests a significant increase in the incidence of sepsis over time as well as a marked decrease in sepsis mortality and death or discharge to hospice. The authors conclude that analysis of clinical data may provide a better understanding of sepsis trends. The accompanying editorial highlights challenges associated with measuring the sepsis incidence and mortality.
WebM&M Case October 1, 2018
… Case Objectives … Realize the importance of early sepsis diagnosis and treatment. Identify challenges in diagnosing sepsis and distinguish common mimickers. Review potential … Recognize the strengths and limitations of different sepsis criteria and clinical decision support tools. …