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.
Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.
Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Int J Qual Health Care. 2022;34:mzac078.
Effective teamwork training for surgical teams can improve post-operative mortality rates. This review aimed to evaluate the effect of a dedicated surgical team (e.g., a team who received technical and/or communication teamwork training) on clinical and performance outcomes. Implementation of dedicated surgical teams resulted in improved mortality rates, but no difference in readmission rates or length of stay.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:b2-b9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.
Merkow RP, Shan Y, Gupta AR, et al. Jt Comm J Qual Patient Saf. 2020;46:558-564.
Postoperative complications can increase costs due to additional healthcare utilization such as further testing, reoperation, or additional clinical services. This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to estimate 30-day costs resulting from postoperative complications. Prolonged ventilation, unplanned intubation, and renal failure were associated with the highest cost per event, whereas urinary tract infection, superficial surgical site infection, and venous thromboembolism were associated with the lowest cost per event.