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.
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.
Newman B, Joseph K, Chauhan A, et al. Health Expect. 2021;24:1905-1923.
Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Communication failures hinder safety of health care delivery and are particularly prevalent in medication errors. This review explores how interdisciplinary work can augment communication during medication processes and highlights interdisciplinary collaboration strategies such as pharmacist engagement in care teams.
Johnson M, Sanchez P, Langdon R, et al. J Nurs Manag. 2017;25:498-507.
Interruptions in nursing care are common and can contribute to errors. In keeping with prior research, this observational study of nurses found that interruptions in medication preparation and administration can compromise patient safety.
Walton MM, Harrison R, Kelly P, et al. BMJ Qual Saf. 2017;26:743-750.
This study elicited patients' reports of adverse events during hospitalization. Researchers found that 7% of hospitalized patients reported experiencing an adverse event and, consistent with prior studies, patients contributed unique contextual data to adverse event reporting.
Polypharmacy, or taking multiple medications, is a risk factor for adverse drug events. This interview study examined how family members participated in medication management for hospitalized patients taking five or more medications and found that communication between family members and health care professionals was insufficient. The authors advocate for providers to proactively engage in discussions with family members as they can know important information regarding patients' medications.
Harrison R, Walton M, Manias E, et al. Int J Qual Health Care. 2015;27:424-42.
Patient perspectives are critical to inform patient safety efforts. This systematic review identified studies of patient experiences with adverse events. Included studies demonstrate that the types of adverse events patients most often identify are medication errors and suboptimal communication, and that patient demographic characteristics influence the likelihood of reporting these events. Calling for increased use of patient experiences in future studies, the authors suggest that investigations into adverse events are incomplete if patient perspectives are not included. These results demonstrate the ongoing need to enhance patient engagement in safety research. A previous AHRQ WebM&M perspective delves further into engaging patients in safety improvement.
Fanning L, Jones N, Manias E. J Eval Clin Pract. 2016;22:156-63.
Adverse drug events continue to contribute to preventable errors for both hospitalized and ambulatory patients. In this study conducted in an Australian emergency department, implementation of automated dispensing cabinets for frequently used medications was associated with a decrease in medication preparation and dispensing errors by nurses.
Braaf S, Riley R, Manias E. J Clin Nurs. 2015;24:1874-1884.
This qualitative study of communication among providers in perioperative care revealed a reliance on written documentation, which was often difficult to find or missing key information, rather than verbal signout. This finding underscores the importance of structured, verbal handoffs to ensure adequate provider communication.
Hor S-Y, Iedema R, Manias E. BMJ Qual Saf. 2014;23:1007-13.
This study used video-reflexive ethnography—a qualitative intervention approach that involves videotaping daily work processes and then using the videos to stimulate further discussion and problem solving—to analyze how clinicians create safe spaces for communication in the busy environment of the intensive care unit.
Manias E, Kinney S, Cranswick N, et al. Ann Pharmacother. 2014;48:1313-31.
Children in pediatric intensive care units (ICUs) are particularly vulnerable to medication errors. This systematic review sought to identify strategies for reducing errors in pediatric ICUs, but found that the published evidence was rather limited in quality and scope. Some of the most promising interventions thus far include smart pumps and computerized provider order entry with decision support.