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.
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
Stenquist DS, Yeung CM, Szapary HJ, et al. J Am Acad Orthop Surg Glob Res Rev. 2022;6:e22.00079.
The I-PASS structured handoff tool has been widely implemented to improve communication during handoffs and patient transfers. In this study, researchers modified the I-PASS tool for use in orthopedic surgery and assessed the impact on adverse clinical outcomes. After 18 months, there was sustained adherence to the tool and the quality of handoffs improved, but no notable changes in clinical outcomes were identified.
Shahian DM, Liu X, Rossi LP, et al. Health Serv Res. 2018;53:608-631.
Measuring safety culture is viewed as a best practice and is endorsed by the Leapfrog Group and the Agency for Healthcare Research and Quality (AHRQ). However, studies have not consistently demonstrated a direct relationship between safety culture and improved patient outcomes. In this observational cohort study, researchers analyzed data from 19,357 discharges for acute myocardial infarction (AMI) across 171 hospitals and associated data from AHRQ Hospital Survey on Patient Safety Culture surveys between 2008 and 2013. They found no association between 30-day AMI mortality and safety culture scores. A recent PSNet interview with Mary Dixon-Woods discussed the evolving concept of safety culture.