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.
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.
Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;78:3745-3759.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21:1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.
Redley B, Raggatt M. BMJ Qual Saf. 2017;26:704-713.
Standardized screening tools are frequently used to assess risk among hospitalized older patients to prevent harm from falls and adverse drug events. This mixed methods study of 11 health services across Victoria, Australia, found that skin integrity and fall risk were consistently assessed, but there was significant variability across institutions with regard to the assessment of nutrition, cognitive function, and medication issues.
Redley B, Bucknall T, Evans S, et al. Int J Qual Health Care. 2016;28:573-579.
Efforts to improve the safety of handoffs have focused on standardizing the signout process. In this mixed methods study, researchers observed 185 anesthetist-to-nurse handoffs from the operating room to the postanesthesia care unit across 3 hospitals. They then conducted focus groups to better understand aspects of safe handoff practices. This work led to the development of a more standardized handoff structure.
Barker AL, Morello RT, Wolfe R, et al. BMJ. 2016;352:h6781.
Falls in hospitalized patients are a common source of preventable harm, and the incident is considered a never event when it results in serious injury. Conducted at six Australian hospitals, this cluster randomized controlled trial sought to evaluate the effectiveness of a bundled intervention on the incidence of falls on adult wards. The bundle included assessing patients' risk for falling along with several widely used tactics to prevent falls. Despite successful implementation of the fall prevention bundle, falls occurred just as frequently on intervention wards as control wards. This study is an important example of the need to rigorously evaluate safety interventions, even those that have high face validity. The authors conclude that since these interventions appear ineffective, organizations should consider disinvestment in these practices because completing ineffective interventions consumes a significant amount of staff time and effort. A WebM&M commentary discussed a case involving a fall resulting in injury.
This study characterizes the types of medication errors documented after introduction of a comprehensive electronic medication management system (that included computerized provider order entry) at two Australian hospitals.