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.
Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.
Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.
Ning H-C, Lin C-N, Chiu DT-Y, et al. PLoS One. 2016;11:e0160821.
Correct identification of patient specimens is crucial to timely and accurate diagnosis. This pre–post study demonstrated substantial improvements in already low rates of patient specimen identification errors following each of three successive strategies: discarding improperly labeled specimens, using barcodes, and automating specimen labeling.
Jen W-Y, Chao C-C. Int J Med Inform. 2008;77:689-97.
This study discovered that use of mobile patient safety information systems can contribute to improvement in services and a reduction in patient risk, but these communication systems may also contribute to physician anxiety.
Youk JH, Kim E-K, Kim MJ, et al. Radiographics. 2007;27:79-94.
The investigators reviewed evidence on ultrasonographic guidance for breast biopsy and provide suggestions on how to minimize sampling error and other problems associated with this diagnostic procedure.
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