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The PSNet Collection: All Content

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.

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Displaying 1 - 19 of 19 Results
Raff L, Moore C, Raff E. Hosp Pract (1995). 2023;51:29-34.
Language barriers can lead to diminished care and threaten patient safety. This retrospective study included patients with rapid response team (RRT) activation and compared disease severity and outcomes for patients whose primary language was Spanish versus English. Findings suggest that language barriers may contribute to delays in RRT activation and delays in care.
Boockvar K, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.
Inaccurate medication reconciliation leads to medication discrepancies and places patients at risk for adverse drug events. Health information exchange can enhance medication safety through improved access to prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access to a regional health information exchange for patients admitted to a single hospital in the intervention arm and without such information access for patients in the control arm. In the first 10 months of the study, the health information exchange provided access to prescribing information from large hospitals and a pharmacy insurance plan, but only hospital prescribing information was available during the last 21 months because the insurance plan began charging for data. Although researchers found no significant difference between the intervention and control groups with regard to the number of medication discrepancies, patients who underwent medication reconciliation with access to pharmacy insurance data had a higher number of medication discrepancies identified than control patients. They conclude that charging for pharmacy data interrupted the positive effect of health information exchange on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing information led to an adverse drug event.
Mull HJ, Rosen AK, Shimada SL, et al. EGEMS (Wash DC). 2015;3:1116.
Trigger tools have been shown to be an efficient way to screen for adverse events. This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient setting. Five of the triggers performed reasonably well for either detecting harm or leading to a change in care plan.
Boockvar K, Blum S, Kugler A, et al. Arch Intern Med. 2011;171:860-1.
This study found that medication reconciliation at hospital admission successfully reduced adverse drug events (ADEs) caused by incorrect admission medication changes. However, the investigators found that appropriate admission medication changes (e.g., withholding antihypertensive medication in a patient presenting with low blood pressure) were also associated with subsequent ADEs, indicating a need for better medication monitoring during hospitalization.
Moore C, Saigh O, Trikha A, et al. J Patient Saf. 2008;4:241-244.
Physicians reported dissatisfaction with their ability to follow up on test results in a timely fashion, with resident physicians frequently reporting an inability to check test results in less than 1 week. The need for standardized methods for following up test results in ambulatory care was noted in a prior study.
Moore C, McGinn T, Halm E. Arch Intern Med. 2007;167:1305-11.
Hospitalized patients are frequently discharged with test results or diagnostic workups pending, with the intention that these will be followed up by outpatient physicians. However, a recent systematic review found that communication between inpatient and outpatient physicians is suboptimal, with primary care physicians frequently being unaware of patients' discharge needs. This study reviewed discharges from the medical service at an academic hospital to determine how often outpatient workups were recommended and completed. More than one-third of recommended outpatient investigations were not completed, frequently because the discharge summary did not contain details of the necessary workup, or because the discharge summary was not available at the time of the patient's clinic visit. Recognition of this problem has led to the development of formal discharge checklists to ensure optimal communication at the time of hospital discharge.
Lin JJ, Dunn A, Moore C. Am J Med Qual. 2006;21:178-84.
This study discovered that nearly 75% of internal medicine residents reported difficulty in following up on test results, with almost one-half citing that the patient's condition deteriorated due to these delays. The authors describe the most commonly reported barriers to timely follow-up (eg, lack of a reminder system, too many competing demands) and discuss the need to address these system deficiencies.
Evans S, Lloyd JF, Stoddard GJ, et al. Ann Pharmacother. 2005;39:1161-8.
Many medications remain at risk for producing an adverse drug event (ADE) despite proper ordering and administration. This study examined more than 4300 ADEs to determine potential risk factors, such as specific patient characteristics. Using a logistic regression model, investigators discovered several risk factors that were present across drug classes with others that remained class-specific. For instance, drug administration route represented a significant risk factor for all ADEs. The article includes detailed tables outlining ADEs captured and risk factors by drug category. The authors conclude that high-risk drugs, as well as high-risk patient and drug administration characteristics, should be vigilantly monitored.
Nebeker JR, Hoffman JM, Weir C, et al. Arch Intern Med. 2005;165:1111-6.
With growing adoption of information technology systems designed to improve the safety and quality of care, this study prospectively evaluated the incidence and epidemiology of adverse drug events (ADEs) in a computerized inpatient setting. After implementation of electronic resources at a Veterans Administration hospital (eg, electronic medical records [EMRs], computerized provider order entry [CPOE], integrated checking of allergies and drug-drug interactions, and bar coding), pharmacists identified and categorized nearly 500 ADEs over a five-month period. Results suggested that 25% of hospitalizations were associated with at least one ADE, accounting for an event rate of 52 ADEs per 100 admissions. The majority of errors that resulted in an ADE occurred in the medication ordering phase. The authors conclude that while there is a capacity to safely administer drugs using computers, more appropriate decision support at high-risk steps would improve current systems.
Bennett CL, Nebeker JR, Lyons A, et al. JAMA. 2005;293:2131-40.
This article summarizes the structure, funding, organization, and methods of an independent and clinically based surveillance program identifying serious and unrecognized adverse drug events (ADEs). The authors provide a detailed account of the process involved, from investigating a possible serious ADE to disseminating their findings to the Food and Drug Administration (FDA), manufacturers, conferences, journals, and the news media. They also share initial results of their operations with details of 16 drugs associated with serious ADEs, including tabular display of the cases reported and the inconsistencies in the dissemination of safety information. The authors conclude by sharing potential implications of the program’s efforts and how this surveillance method may provide additional opportunity to detect and prevent serious ADEs.