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.
Latimer S, Hewitt J, de Wet C, et al. J Clin Nurs. 2023;32:1276-1285.
… Medication reconciliation at hospital discharge has become a mainstay of patient safety efforts with most of the focus … in medication reconciliation. … Latimer S, Hewitt J, deWet C, et al. Medication reconciliation at hospital …
Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.
Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.
Stocks SJ, Donnelly A, Esmail A, et al. BMJ Open. 2018;8:e020952.
… care providers. Researchers elicited adverse events from a nationally representative sample of British outpatients. … frequently problems with medications, accessing care in a timely way, and diagnostic errors . …
McNab D, Bowie P, Ross A, et al. BMJ Qual Saf. 2018;27:308-320.
This systematic review found that pharmacist-led medication reconciliation after hospital discharge reduced medication discrepancies. However, the pooled studies did not demonstrate changes in the readmission rate or emergency department visits following medication reconciliation. The authors suggest further research is needed to determine the effect of medication discrepancies on patient safety.
Vosper H, Hignett S, Bowie P. Med Teach. 2017;40:357-363.
Human factors engineering helps improve human performance and reduce the risks associated with user error. This commentary discusses the current integration of human factors engineering theories and methods into education and training. The authors outline tactics to help educators translate human factors engineering concepts into their programs such as building on what works well.
de Wet C, Black C, Luty S, et al. BMJ Qual Saf. 2017;26:335-342.
… … BMJ Qual Saf … The trigger tool approach, in which a prespecified value triggers medical record review to identify patient safety issues, is a method to detect adverse events. This study offered … from trigger reviews, suggesting that trigger reviews are a feasible strategy to enhance outpatient safety. …
Hignett S, Lang A, Pickup L, et al. Ergonomics. 2018;61:5-14.
Barriers to achieving safe, high-quality health care are well known. This study described the myriad challenges faced by the National Health Service (NHS) in its quest to provide optimal patient care. The authors suggest that the NHS lags behind other safety critical industries in applying human factors principles.
Bowie P, Price J, Hepworth N, et al. BMJ Open. 2015;5:e008968.
… similar to prior studies . The authors describe a conceptual model to comprehensively address the safety of … laboratory testing and results management in primary care, a useful step for future interventions. …
Ahmed M, Arora S, McKay J, et al. BMC Fam Pract. 2014;15:206.
… BMC Fam Pract … BMC Fam Pract … There is a consensus that training in patient safety must be … on the core skills that students should be taught. A prior study used a consensus approach to identify the key … widely in the United Kingdom. … Ahmed M, Arora S, McKay J, et al. Patient safety skills in primary care: a …
Bowie P, Halley L, McKay J. BMJ Open. 2014;4:e004245.
In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.