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.
Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.
Law AC, Stevens JP, Hohmann S, et al. Crit Care Med. 2018;46:1563-1569.
Inadequate nurse staffing in hospitals leads to increased morbidity and mortality. Two proposed explanations are that nurses provide surveillance and reassessment, which are particularly important for seriously ill patients, and that inadequate staffing leads to missed nursing care. This retrospective cohort study assessed the impact of a 2016 Massachusetts law that mandated minimum nursing ratios in intensive care units. Mortality and complication rates did not change after the law's passage, nor did they differ from states without staffing ratio mandates. Nurse staffing was not substantially higher in Massachusetts after the mandate when compared with other states. Two accompanying editorials highlight the challenges of measuring and promoting appropriate nursing care, which authors argue cannot be simply defined with a staffing ratio. A PSNet perspective and a WebM&M commentary further explore the safety risks of missed nursing care.
Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.
Implementing a comprehensive safety program, which included teamwork training, additional staffing and reduction of work hours, electronic medical records, and a dedicated patient safety nurse, was associated with a sharp reduction in malpractice lawsuits and sentinel events at an academic hospital.
Wagner MJ, Wolf S, Promes S, et al. J Emerg Med. 2010;39:348-55.
This commentary, by leaders in the emergency medicine field, discusses the implications of the Institute of Medicine's recommendations regarding resident work hours for emergency medicine residency training. Some, but not all, of the IOM's recommendations were included in the recently released duty hour proposal from the Accreditation Council for Graduate Medical Education.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.