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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 212 Results
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.
Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.
Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.
Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
Barclay ME. JAMA Health Forum. 2022;3:e221006.
The Centers for Medicare & Medicaid Services (CMS) provides individual and composite quality and safety ratings (i.e., star ratings) for hospitals and other healthcare facilities on its Care Compare website. This study evaluated three alternative methods for rating facilities and compared them to the CMS star ratings. Hospitals were frequently assigned a different star rating using the alternate methods, typically between adjacent star categories.
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Front Med (Lausanne). 2022;9:875426.
Hospital-acquired conditions impact not only patient morbidity and mortality, but are also a significant financial burden. This review identified eight categories of hospital-acquired conditions (i.e., overall medical error, medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide) and more than 100 proposed interventions addressing those conditions.
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022;235:494-499.
Unintentionally retained surgical items (RSI) can have a devastating impact on patient health and safety. One method to reduce the incidence of RSI is radiofrequency (RF) detection. Nearly one million operations in New York state were analyzed for the rate of RSI before and after the use of RF was required and simultaneous TeamSTEPPS training was provided. The incidence of RF-detectable items was significantly reduced, but the rate of non-RF-detectable items was not.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;Epub Aug 1.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.
Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;10:1844-1855.e3.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels. 
Virnes R-E, Tiihonen M, Karttunen N, et al. Drugs Aging. 2022;39:199-207.
Preventing falls is an ongoing patient safety priority. This article summarizes the relationship between prescription opioids and risk of falls among older adults, and provides recommendations around opioid prescribing and deprescribing.
Damoiseaux-Volman BA, Raven K, Sent D, et al. Age Ageing. 2022;51:afab205.
According to an Agency for Healthcare Research and Quality study, an estimated 700,000 to 1 million hospitalized patients fall each year. This study assessed the impact of potentially inappropriate medications (PIM) on falls in older adults and compared the impact of three deprescribing tools on inpatient falls. PIMs identified by section K of the Screening Tool of Older Persons' Prescriptions (STOPP) had the strongest association with inpatient falls.
Patel TK, Patel PB, Bhalla HL, et al. Eur J Clin Pharmacol. 2022;78:267-278.
Adverse drug events are common and often result in preventable patient harm. Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related deaths contributed to 5.6% of all inpatient hospital deaths. The authors estimated that almost half of drug-related deaths are preventable.
Mimmo L, Harrison R, Travaglia J, et al. Dev Med Child Neurol. 2022;64:314-322.
Children with intellectual disabilities may experience poor-quality care and be at higher risk for patient safety events. This cross-sectional study including patients admitted to two children’s hospitals in Australia found that children with intellectual disabilities had longer hospital stays and experienced more admissions with at least one clinical incident (e.g., medication incidents, documentation errors) compared to children without intellectual disabilities.
Fischer H, Hahn EE, Li BH, et al. Jt Comm J Qual Patient Saf. 2022;48:222-232.
While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;18:3534-3541.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
Oura P. Prev Med Rep. 2021;24:101574.
Accurate measurement of adverse event rates is critical to patient safety improvement efforts. This study used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the United States compared to non-adverse event deaths. The author estimates that 0.16-1.13% of deaths are attributed to an adverse event. Procedure-related complications contributed to the majority of adverse event deaths. The risk of death due to adverse event was higher for younger patients and Black patients.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2022;78:2015-2029.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors