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.
Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;22:2196-2200.
Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.
Bhasin S, Gill TM, Reuben DB, et al. N Engl J Med. 2020;383:129-140.
This study randomized primary care practices across ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury, which included risk assessment and individualized plans administered by specially trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Fisher K, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Cutrona SL, Fouayzi H, Burns L, et al. J Gen Intern Med. 2017;32:1210-1219.
Electronic health record alerts contribute to alert fatigue and increase provider workload. Some alerts are more time-sensitive than others and a delayed response can adversely impact patient safety. This study found that time-sensitive alerts were less likely to be opened by primary care providers within 24 hours if the provider's InBasket had a high number of notifications at the time of alert delivery or if the alert was sent on the weekend.
Kane-Gill SL, Achanta A, Kellum JA, et al. World J Crit Care Med. 2016;5:204-211.
Medication administration technologies can help collect data to enhance processes and reduce medication errors. This commentary discusses how organizations are using clinical decision support systems to track problems and incorporating different data sets to prevent adverse drug events.
Fisher K, Ahmad S, Jackson M, et al. Patient Educ Couns. 2016;99:1685-93.
This qualitative study used in-depth interviews with family members of critically ill patients to assess their perception of safety and quality problems. Nearly half of surrogate decision makers identified at least one safety concern, most often relating to communication from clinicians. Patient and family identification of errors is an important strategy for engaging patients in safety efforts.
Mazor KM, Smith KM, Fisher K, et al. Ann Intern Med. 2016;164:618-9.
Although patients have been increasingly encouraged to speak up about concerns as a way to improve safety, health care institutions often have no system in place to ensure such concerns are promptly addressed. This commentary explores the disconnect between intention and action and suggests steps to be taken so that health systems can achieve benefits of patient engagement initiatives.
Mazor KM, Roblin DW, Greene SM, et al. BMJ Qual Saf. 2016;25:787-95.
Despite widespread calls for full disclosure of medical errors, physicians often choose their words carefully rather than explicitly detail how errors may have occurred. This study used two hypothetical vignettes to explore primary care providers' willingness to disclose errors involving multiple providers. The first vignette included a diagnosis of breast cancer that may have been delayed due to miscommunication with a covering physician. The second vignette described a breakdown in care coordination between providers responding to a patient's telephone call concerns, resulting in an adverse outcome. The majority of respondents said they would provide only a partial disclosure in either situation. More than three-quarters of physicians in the breast cancer case said they would offer either no information or would make vague references to miscommunication. In a prior WebM&M interview, Dr. Thomas Gallagher, the senior author of this study, discussed error disclosure.
Smith KJ, Handler S, Kapoor WN, et al. Am J Med Qual. 2016;31:315-22.
Medication inconsistencies are common at hospital discharge. This study found that computerized discharge medication reconciliation, combined with automatic communication of the reconciled medication list to the patient's primary care physician, reduced discharge medication errors.
Kanaan AO, Donovan JL, Duchin NP, et al. J Am Geriatr Soc. 2013;61:1894-1899.
Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.
Wagner LM, Castle NG, Handler S. Geriatr Nurs. 2013;34:112-5.
Safety problems—particularly medication errors—are common in nursing homes and other long-term care settings. Prior studies have also shown that safety culture in long-term care settings is generally poor. One manifestation of poor safety culture can be that errors go unreported, and this survey of nearly 400 nursing homes found evidence confirming that substandard error reporting is a problem in long-term care. Few nursing homes surveyed used computerized methods to report errors or to monitor adverse event data, and respondents reported both technological and cultural barriers to voluntary error reporting. As most nursing homes also did not use computerized provider order entry or any other form of electronic medical record, the authors recommend more widespread adoption of health information technology in general, and error reporting systems specifically, in the long-term care setting. One such system for voluntarily reporting medication errors has been successfully implemented in nursing homes in North Carolina.
Tjia J, Field T, Mazor KM, et al. Am J Geriatr Pharmacother. 2012;10:323-30.
Dementia appeared to be an independent risk factor for medication errors among a cohort of geriatric nursing home patients who were prescribed the anticoagulant warfarin. Increased nursing staff time seemed to mitigate this risk.
… & Medicaid Services; 2010. [Available at] 3. Gurwitz JH, Field TS, Tjia J, Mazor K. Improving medication safety in the … 9781599404158. 4. Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. Nurse–physician communication in the … RP. Dabigatran—uncharted waters and potential harms. Ann Intern Med. 2012;157:66-68. [go to PubMed] 11. American …
This piece, written by a national leader in safe use of medications in elderly patients, discusses strategies for improving the quality and safety of medication use in the nursing home setting.
McKibbon A, Lokker C, Handler S, et al. J Am Med Inform Assoc. 2012;19:22-30.
This systematic review identified 87 randomized controlled trials assessing the effect of information technology on various aspects of medication safety, including studies of computerized provider order entry. Although processes of care consistently improved, few studies demonstrated improvement in clinical outcomes.