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.
McGinty EE, Thompson DA, Pronovost P, et al. J Nerv Ment Dis. 2017;205:495-501.
Patients with underlying psychiatric conditions may be particularly vulnerable to adverse events. This retrospective study analyzed 790 medical or surgical hospitalizations among adults with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems factors were correlated with adverse events. The authors suggest that improving safety in patients with mental illness will require multifaceted interventions.
Kennedy-Hendricks A, Gielen A, McDonald E, et al. JAMA Intern Med. 2016;176:1027-9.
The prescription opioid epidemic is one of the most pressing current patient safety issues, resulting in thousands of deaths yearly. This survey of patients who used prescription opioids in the past year found that more than 20% had shared their medications with someone else, and nearly half had never received information on safe storage or disposal of these medications. The Centers for Disease Control and Prevention recently published guidelines on safe opioid prescribing.
Patients with serious psychiatric disorders, such as schizophrenia and bipolar disorder, often require high-risk medications and experience medical comorbidities. This cohort study assessed the frequency of preventable adverse events during medical hospitalizations in patients with serious mental illness. Preventable adverse events, primarily medication errors, were very common among these patients and were associated with physical injury during hospitalization. The study could not assess the causes of the adverse events, but prior studies have shown that medication administration errors are frequent in psychiatric inpatients. A WebM&M commentary discussed a case of a preventable death occurring shortly after a patient with schizophrenia was discharged from a medical hospitalization.