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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 - 9 of 9 Results
Arbaje AI, Greyson S, Keita Fakeye M, et al. J Patient Saf Risk Manag. 2023;28:201-207.
Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.
DeCherrie LV, Leff B, Levine DM, et al. Jt Comm J Qual Patient Saf. 2022;48:180-184.
Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.
Franzosa E, Gorbenko K, Brody AA, et al. J Am Geriatr Soc. 2021;69:300-306.
The COVID-19 pandemic has resulted in numerous challenges for delivering health care to medically complex patients. This qualitative study explored how home-based primary care practices (HBPCs, which deliver care to individuals lacking access to traditional primary care) provided patient care during the pandemic. Strategies included increased use of virtual care, communication tools such as daily huddles, and mental health services for patients experiencing depression and isolation.
Bristol AA, Schneider CE, Lin S-Y, et al. J Healthc Qual. 2019.
Care transitions between hospitals and community settings have been identified as a source of negative patient safety outcomes, such as medication errors or other adverse events. This systematic review focused on transitions of care within hospitals (such as within the same unit or between units) and found two studies demonstrating that the risk of adverse events - such as medication errors, infections or falls - increased as patients experienced three or more transfers. A prior PSNet WebM&M also discussed medication errors that can arise during transitions between hospital units.
Mann E, Zepeda O, Soones T, et al. Home Health Care Serv Q. 2018;37:177-186.
In "Hospital at Home" (HaH) programs, patients receive inpatient medical treatment such as intravenous medications, daily laboratory monitoring, and basic imaging in their home under close clinician supervision. Among 50 HaH patients in New York, 22% experienced an adverse drug event. A WebM&M commentary discussed medication challenges unique to the home.
Arbaje AI, Hughes A, Werner N, et al. BMJ Qual Saf. 2019;28:111-120.
Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.
Brody AA, Gibson B, Tresner-Kirsch D, et al. J Am Geriatr Soc. 2016;64:e166-e170.
… reconciliation at the time of hospital discharge is a key patient safety practice. This study found a high prevalence of discrepancies between older patients' …
Arbaje AI, Werner NE, Kasda EM, et al. J Patient Saf. 2020;16:52-57.
Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.