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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 41 Results
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319:1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Walker S, Mason A, Quan P, et al. Lancet. 2017;390:62-72.
The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.
Li L, Rothwell PM, Study OV. BMJ. 2016;353:i2648.
The weekend effect refers to the fact that mortality for several common conditions is higher in patients admitted on weekends compared to weekdays. While the mechanism for this effect is unclear, it likely varies for different disease processes. For example, prior studies have postulated that a weekend effect exists for patients with acute stroke. However, this study analyzed a large British database and found that many patients with a history of stroke who were later hospitalized for other reasons had their admission diagnosis inaccurately documented as acute stroke. This inaccuracy occurred more frequently in patients admitted on weekdays. Because the weekday admissions included many patients who were hospitalized for less morbid conditions, mortality appeared lower for patients admitted on weekdays than on weekends. When data was reanalyzed to include only those patients with a true acute stroke, no weekend effect was found. This study demonstrates the limitations of administrative data in analyzing patient safety issues.
Murphy DR, Wu L, Thomas EJ, et al. J Clin Oncol. 2015;33:3560-7.
Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.
Starmer AJ, Spector ND, Srivastava R, et al. New Engl J Med. 2014;371:1803-1812.
The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&M commentary.
Starmer AJ, Sectish TC, Simon DW, et al. JAMA. 2013;310:2262-2270.
Handoff improvement is a national patient safety priority. The Accreditation Council for Graduate Medical Education now requires residency programs to provide formal handoff education to trainees. This study evaluated the implementation of an inpatient handoff bundle for pediatric resident physicians. The multifaceted intervention included team training, standardized communication, electronic documentation, and new team handoff structures. In the uncontrolled, before-and-after analyses, medical errors and preventable adverse events decreased substantially. The intervention did not adversely affect resident workflow. Residents were found to spend more time in direct contact with patients in the post-intervention period. A related editorial notes that this study presents promising evidence that improving handoffs can reduce patient harm.
Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.
Preventing readmissions after hospital discharge is a national policy priority. The Partnership for Patients has established a goal of reducing preventable readmissions by 20% by 2013, and hospitals now face financial penalties for excess readmission rates. However, the proportion of readmissions that is truly preventable remains unclear, as prior studies have found that only 1 in 5 readmissions may be preventable. This case series from the integrated Kaiser Permanente system found that nearly half of their 30-day readmissions were at least possibly preventable (with 11% being completely preventable). Most readmissions had multiple contributing causes, and interestingly, use of strategies to prevent readmissions such as postdischarge telephone calls and early primary care follow-up appointments varied widely across the 18 hospitals in the study. A potentially preventable readmission due to a medication error is discussed in an AHRQ WebM&M commentary.
Li SYW, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.
Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-7.
Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.
Voss R, Gardner R, Baier R, et al. Arch Intern Med. 2011;171:1232-7.
The Partnership for Patients has set a goal of reducing preventable hospital readmissions 20% by the year 2013. This goal was achieved by the landmark care transitions study. However, since that study was conducted in an integrated health care system, concerns linger about the generalizability of the intervention to other settings. This study, funded by the Centers for Medicare and Medicaid Services, sought to evaluate the real world effectiveness of the care transitions intervention at six hospitals in a non-integrated health care system. Despite logistical challenges, the intervention successfully reduced readmissions by 36% in patients who received it compared with patients who did not receive any component of the intervention. As hospitals continue to investigate ways of preventing readmissions and reducing adverse events after discharge, this study provides reinforcement for comprehensive interventions that attempt to bridge the gap between inpatient and outpatient care.
Young JQ, Ranji SR, Wachter RM, et al. Ann Intern Med. 2011;155:309-15.
The beginning of residency training for new interns has long been rumored to result in preventable harm for patients, a phenomenon known as the "July Effect" in the US and by the more macabre term "August killing season" in the UK. However, prior studies have reached conflicting conclusions about whether the "July Effect" truly exists. This systematic review of 39 studies provides the first comprehensive evidence that being hospitalized in July may actually be harmful, as a subset of larger and higher quality studies did find that mortality increased and efficiency of care decreased in association with new residents assuming their duties. Unfortunately, most studies included in the review had methodological flaws, meaning that the exact degree of harm could not be quantified.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Catchpole K, Sellers R, Goldman A, et al. Qual Saf Health Care. 2010;19:318-22.
Transfer of patients from the operating room to intensive care involves exchange of complex information between multiple providers in a short period of time.  In an innovative effort to apply principles from other industries to medicine, this study used interviews with the managers of Formula One auto racing teams to determine the key elements of racing "pit stops" and draw lessons for improving the safety of the postoperative handover process. The key lessons learned from the auto racing approach—proactive planning, active management of the handover process using information technology, and post hoc learning by data monitoring and analysis—have subsequently been applied to standardize and improve the postoperative handover process.
Nasca TJ, Day SH, Amis S, et al. N Engl J Med. 2010;363:e3.
This article summarizes the Accreditation Council for Graduate Medical Education's proposed new regulations on housestaff duty hours. The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour weekly limit. Rather than narrowly focusing on duty-hour restrictions, the recommendations take a broad approach to maximizing patient safety in training environments through targeted reductions in work hours for first-year residents, enhanced supervision by attending physicians, standardizing expectations around handoffs and signouts, and engaging residents in safety and quality improvement efforts. Although the current 80-hour work week will be preserved, the new regulations would eliminate extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report). The current regulations, implemented in 2003, have improved residents' quality of life but have not positively impacted patient safety or educational outcomes. The ACGME acknowledged this evidence in crafting recommendations that seek to establish a culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage residents while allowing more autonomy for senior trainees.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
Jha AK, Chan DC, Ridgway AB, et al. Health Aff (Millwood). 2009;28:1475-1484.
The seminal Institute of Medicine report To Err Is Human estimated that preventable errors cost the US health care system more than $17 billion annually. Although hospitals themselves currently bear only a small proportion of these costs, payers are increasingly seeking to realign incentives to both improve safety and control costs. This study examined the costs associated with both preventable adverse events and redundant tests (duplicate tests ordered for the same patient by different physicians). The authors estimate that eliminating preventable adverse events (principally health care–associated infections) alone could save the US health system more than $16 billion annually, with an additional $8 billion in savings potentially achievable by eliminating redundant tests. The Centers for Medicare and Medicaid Services' policy eliminating reimbursement for certain preventable conditions is an attempt to address this issue. A companion article explains that the savings realized by this policy are likely to be minimal.
Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-6.
Adverse events after hospital discharge are a continued threat to patient safety and a significant source of communication failures, particularly for tests that are pending at discharge. This study reviewed nearly 700 discharge summaries from two academic centers and found that only 16% of pending tests were mentioned and that only 13% of discharge summaries listed all pending tests. Equally concerning was that follow-up providers' information was documented in only 67% of cases. Recognition of these problems has led to the development of discharge checklists and reengineering of the process. A past AHRQ WebM&M perspective and interview discussed issues around safe care transitions.