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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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Curated Libraries
September 13, 2021
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...
Kim MM, Barnato AE, Angus DC, et al. Arch Intern Med. 2010;170:369-76.
Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.
Moldenhauer K, Sabel A, Chu ES, et al. Jt Comm J Qual Patient Saf. 2009;35:164-74.
A national campaign to save lives in the hospital setting initially catalyzed implementation of rapid response systems. Although past research led to controversy over their widespread adoption, the ability to identify at-risk patients and prevent them from clinically deteriorating remains important. This study developed a clinical triggers program that focused on systematic use of existing housestaff teams to respond to patients in distress. Rather than a dedicated and resource-intensive rapid response team, this hospital required nurses to trigger a call to the primary team based on specific physiologic parameters, and then required responding housestaff to complete a form following direct communication with the bedside nurse. The guidelines also required timely discussion with an attending physician, which ultimately led to a decrease in non-ICU cardiopulmonary arrests and ICU bounceback rates. While their model may apply only to similar teaching institutions, it does provide a unique prototype for addressing failure to rescue initiatives that leverage existing resources rather than creating new ones.
Pronovost PJ, Berenholtz SM, Goeschel C, et al. J Crit Care. 2008;23:207-212.
The Keystone ICU project is a landmark achievement in patient safety. This project, funded by AHRQ, represented a collaboration between patient safety experts at Johns Hopkins University and the Michigan Hospital Association to improve patient safety in 99 intensive care units (ICUs). This article discusses implementation of the comprehensive unit-based safety program, which was the cornerstone of the project, and provides detailed information on the organizational change model used as well as the interventions that were implemented. The remarkable successes achieved by this project include near-elimination of catheter-related bloodstream infections and a significant improvement in the safety culture in participating ICUs. The project's principal investigator, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M near the project's conclusion in 2005.