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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 51 Results
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
Oura P, Sajantila A. J Public Health Res. 2022;11:227990362211399.
Although patient safety is a national priority, preventable harm among patients remains high. After analyzing national death certificate data from 1999 through 2019, researchers in this study found that medical adverse events were listed as the underlying cause of death in 0.24% of deaths. From 2014 to 2019, researchers identified a nearly 16% annual increase in deaths attributed to adverse events, primarily driven by procedure-related adverse events and possibly related to the implementation of ICD-10 in 2015.
Costin I-C, Marcu LG. Crit Rev Oncol Hematol. 2022;178:103798.
Radiotherapy errors can be significant and sometimes fatal. This systematic review describes errors in patient set up based on verification systems, the immobilization devices used, and the patient’s positioning during breast cancer treatment. The advantages and drawbacks of the most common position verification systems, error types associated with immobilization systems, and the influence of treatment position are reviewed.
Moody A, Chacin B, Chang C. Curr Opin Anaesthesiol. 2022;35:465-471.
Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.
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, collaborative initiatives, teamwork, and trigger tools.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  
Perspective on Safety December 22, 2020

This piece discusses prevalent adverse events in dental care and the challenges in identifying these patient safety events.

Perspective on Safety December 22, 2020

Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.   

Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

Livingston E, Howell EA. JAMA Clin Rev. April 2, 2019.

Maternal mortality in the United States is gaining increased attention as a patient safety concern. This podcast discusses conditions known to challenge maternal safety, the high incidence of preventable harm in this population, and care bundles as an improvement strategy. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.
Wong LP. Semin Dial. 2019;32:266-273.
Patients with end-stage renal disease are vulnerable to adverse events in dialysis. This commentary outlines a team-based approach to improving safety in dialysis care. The authors highlight the importance of multidisciplinary teamwork, accountability, and coleadership to develop high-functioning teams for safe dialysis.
Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.
Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.
Hagley GW, Mills PD, Shiner B, et al. Phys Ther. 2018;98:223-230.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Murray P. Washington, DC; Senate Health, Education, Labor, and Pensions Committee; 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
WebM&M Case December 1, 2014
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola.
D'Amour D, Dubois C-A, Tchouaket E, et al. Int J Nurs Stud. 2014;51:882-91.
Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.