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.
Wang E, Arnold S, Jones S, et al. JAMA Netw Open. 2022;5:e2142382.
This study examined whether a full-integration approach to a hospital merger and acquisitions (consisting of early leadership integration, rapid transition to electronic health record systems, local ownership of quality metrics, dashboards featuring system goals and actional analytics, and use of value-based and analytic-driven interventions) improved patient outcomes. Compared to the situation pre-merger, findings show that in-hospital mortality and hospital-acquired infection rates were lower, while patient satisfaction were higher after the full-integration merger.
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.
Wang JS, Fogerty RL, Horwitz LI. PLoS One. 2017;12:e0186075.
This secondary data analysis found that most patients admitted to the hospital have their medications changed to another medication of the same class to be consistent with the hospital formulary. Researchers found that patients who undergo this therapeutic interchange are more likely to have errors in medication reconciliation at the time of hospital discharge compared to patients whose medications are not changed. The authors suggest that improved information technology may address this patient safety concern.
Krumholz HM, Wang K, Lin Z, et al. N Engl J Med. 2017;377:1055-1064.
Avoiding readmissions has been an important safety goal, especially since Medicare has implemented nonpayment policies. Patient factors like health literacy and access to outpatient follow-up care have been implicated in previous research on readmissions. In contrast, this study sought to determine whether hospital quality affects readmission rates. By examining patients with multiple admissions for the same diagnosis but at different hospitals, they were able to focus on the effect of the hospital alone. Hospitals were divided into four tiers based on their known overall rate of readmissions, and then investigators assessed whether a given patient was more or less likely to be readmitted based on these tiers. They found a higher likelihood of a given patient being readmitted at hospitals in the tier with the most readmissions compared to those hospitals in the lowest readmission tier. The authors conclude that hospital readmissions are in part due to hospital factors as well as individual factors. This finding suggests that targeting hospital safety practices could reduce readmissions.
Dharmarajan K, Wang Y, Lin Z, et al. JAMA. 2017;318:270-278.
Reducing hospital readmissions is a major patient safety priority. The Centers for Medicare and Medicaid Services policy of nonpayment for readmissions for certain conditions has decreased their incidence. However, the impact of this policy on 30-day postdischarge mortality remains unknown. Researchers conducted a retrospective study of Medicare fee-for-service patients admitted to hospitals with heart failure, acute myocardial infarction, or pneumonia from 2008 through 2014. They calculated monthly 30-day risk-adjusted readmission rates and 30-day risk-adjusted mortality rates for each condition at each hospital. They then examined the association between hospitals' monthly trends in 30-day readmissions and 30-day mortality after discharge for each condition. The authors found a weak but significant association between decreased 30-day readmissions and lower 30-day postdischarge mortality and conclude that efforts to reduce readmissions for the analyzed conditions do not lead to increased mortality. A previous WebM&M commentary discussed an incident involving a patient readmitted to the hospital after being discharged to a skilled nursing facility.
Desai NR, Ross JS, Kwon JY, et al. JAMA. 2016;316:2647-2656.
This retrospective analysis of Medicare claims data found that the decrease in readmissions following the Hospital Readmission Reduction Program occurred across target conditions and other diagnoses. Hospitals penalized by the Centers for Medicare and Medicaid Services had greater reductions in readmissions for the targeted conditions. These results support the effectiveness of the nonpayment policy.
Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf. 2016;25:e7.
The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.
Jenq GY, Doyle MM, Belton BM, et al. JAMA Intern Med. 2016;176:681-90.
Reducing readmissions has become a central target for hospitals, mostly spurred by Medicare policies that penalize excessive readmission rates. Although some intensive programs have successfully avoided readmissions, many other efforts have failed. This study at an urban academic medical center involved targeting only high-risk patients and providing them with a personalized transitional care plan that included detailed medication reconciliation and follow-up phone calls, as well as linking them with community resources. Over a 2-year period, the readmission rate dropped from 21.5% to 19.5% in the intervention group and from 21.1% to 21.0% in the control population. This 9% relative reduction in readmissions is significant, though it translates to a number-needed-to-treat of 50 (to avoid 1 readmission), which is quite high for a resource-intensive intervention. A prior PSNet perspective discussed strategies for reducing hospital readmissions.
Schuster KM, Jenq GY, Thung SF, et al. J Am Med Inform Assoc. 2014;21:e352-e357.
A computerized physician sign-out note embedded into the electronic medical record was designed at Yale–New Haven Hospital to facilitate patient handoffs. This study found that many non-physician health professionals have also been using the sign-out tool, which is felt to be an unintended positive consequence of the system.
Schoenfeld AR, Al-Damluji MS, Horwitz LI. BMJ Qual Saf. 2014;23:66-72.
Despite use of a standardized template, the inclusion of key data elements in inpatient signouts varied widely between specialties in this study conducted at a tertiary care teaching hospital. The authors attribute this finding to cultural differences across specialties and acknowledge that a one-size-fits-all approach to signouts may not be appropriate.
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. J Hosp Med. 2013;8:609-14.
Despite consensus that the signout process between physicians should be standardized to reduce the risk of errors, the utility of written versus verbal signouts is still under investigation. Much research on effective signout techniques has focused on handoffs between residents, with comparatively little data on signouts between attending physicians. This descriptive study of hospitalists' signouts found that most hospitalists relied primarily on the signout to respond to overnight questions and consulted electronic medical records or other data sources less frequently. However, the utility of the written signout varied widely despite use of a template—for example, the written signout was not particularly helpful in assessing possible changes in a patient's clinical status. Given that information transfer with verbal signout has also been shown to be inadequate, this study indicates a need to further optimize both verbal and written signouts. An AHRQ WebM&M perspective discussed the current knowledge base regarding safe transitions of care for inpatients.
Ziaeian B, Araujo KLB, Van Ness PH, et al. J Gen Intern Med. 2012;27:1513-1520.
Medication discrepancies remain common at hospital discharge, despite intense efforts to improve medication reconciliation processes. Conducted in a geriatric patient population, this prospective cohort study found a similar incidence of medication discrepancies at discharge compared with prior studies, but concerningly, patients were unaware of most of these errors. Both provider errors and patient misunderstanding occurred more frequently for medications prescribed for conditions other than the primary hospital diagnosis, indicating that disease-specific efforts to improve medication safety may miss many errors.
Bradley EH, Curry LA, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-14.
Patients hospitalized for acute myocardial infarction (AMI) or congestive heart failure (CHF) are more likely to require hospital readmission within 30 days of discharge. Intensive efforts are underway to reduce readmissions in these patients, spurred by federal policies that penalize hospitals with excess readmission rates. However, this survey of nearly 600 hospitals found widely varying implementation of specific strategies to decrease readmissions in these patients, despite nearly all hospitals having declared reducing AMI and CHF readmissions to be a priority. The authors acknowledge that a lack of evidence supporting strategies to reduce readmissions, as well as variability in the underlying causes of readmissions between hospitals, may have influenced which interventions were implemented at different hospitals.
Lovig KO, Horwitz LI, Lipska K, et al. Jt Comm J Qual Patient Saf. 2012;38:403-407.
A retrospective chart review revealed that approximately 1 in 8 patients with diabetes was discharged without any antihyperglycemic therapy following acute myocardial infarction. Almost 90% of these omissions lacked justification, suggesting widespread errors in medication reconciliation.
Although adverse events after discharge remain a common source of preventable readmissions, this study found that internal medicine residents felt the discharge process was largely uncoordinated and nonstandardized.