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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 - 20 of 27 Results
Durstenfeld MS, Statman S, Dikman A, et al. Am J Med Qual. 2019;34:590-595.
Academic medical centers are working to increase resident engagement in patient safety work. Building on Reason's system failure investigation model, this commentary describes the integration of monthly educational opportunities into actual improvement efforts. Core elements of the program rely on effective case selection, root cause analysis, and resident-led discussion.
Wang JS, Fogerty RL, Horwitz LI. PLoS One. 2017;12:e0186075.
This secondary data analysis found that most patients admitted to the hospital have their medications changed to another medication of the same class to be consistent with the hospital formulary. Researchers found that patients who undergo this therapeutic interchange are more likely to have errors in medication reconciliation at the time of hospital discharge compared to patients whose medications are not changed. The authors suggest that improved information technology may address this patient safety concern.
Desai NR, Ross JS, Kwon JY, et al. JAMA. 2016;316:2647-2656.
This retrospective analysis of Medicare claims data found that the decrease in readmissions following the Hospital Readmission Reduction Program occurred across target conditions and other diagnoses. Hospitals penalized by the Centers for Medicare and Medicaid Services had greater reductions in readmissions for the targeted conditions. These results support the effectiveness of the nonpayment policy.
Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf. 2016;25:e7.
The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.
Jenq GY, Doyle MM, Belton BM, et al. JAMA Intern Med. 2016;176:681-90.
Reducing readmissions has become a central target for hospitals, mostly spurred by Medicare policies that penalize excessive readmission rates. Although some intensive programs have successfully avoided readmissions, many other efforts have failed. This study at an urban academic medical center involved targeting only high-risk patients and providing them with a personalized transitional care plan that included detailed medication reconciliation and follow-up phone calls, as well as linking them with community resources. Over a 2-year period, the readmission rate dropped from 21.5% to 19.5% in the intervention group and from 21.1% to 21.0% in the control population. This 9% relative reduction in readmissions is significant, though it translates to a number-needed-to-treat of 50 (to avoid 1 readmission), which is quite high for a resource-intensive intervention. A prior PSNet perspective discussed strategies for reducing hospital readmissions.
de Lusignan S, Mold F, Sheikh A, et al. BMJ Open. 2014;4:e006021.
This systematic review explored many aspects surrounding patients' online access to electronic health records. Although patients seem to appreciate the access, health professionals have multiple concerns about privacy and increased workloads. No studies have reported any effects of patient online access on health outcomes.
Schuster KM, Jenq GY, Thung SF, et al. J Am Med Inform Assoc. 2014;21:e352-e357.
A computerized physician sign-out note embedded into the electronic medical record was designed at Yale–New Haven Hospital to facilitate patient handoffs. This study found that many non-physician health professionals have also been using the sign-out tool, which is felt to be an unintended positive consequence of the system.
Schoenfeld AR, Al-Damluji MS, Horwitz LI. BMJ Qual Saf. 2014;23:66-72.
Despite use of a standardized template, the inclusion of key data elements in inpatient signouts varied widely between specialties in this study conducted at a tertiary care teaching hospital. The authors attribute this finding to cultural differences across specialties and acknowledge that a one-size-fits-all approach to signouts may not be appropriate.
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. J Hosp Med. 2013;8:609-14.
Despite consensus that the signout process between physicians should be standardized to reduce the risk of errors, the utility of written versus verbal signouts is still under investigation. Much research on effective signout techniques has focused on handoffs between residents, with comparatively little data on signouts between attending physicians. This descriptive study of hospitalists' signouts found that most hospitalists relied primarily on the signout to respond to overnight questions and consulted electronic medical records or other data sources less frequently. However, the utility of the written signout varied widely despite use of a template—for example, the written signout was not particularly helpful in assessing possible changes in a patient's clinical status. Given that information transfer with verbal signout has also been shown to be inadequate, this study indicates a need to further optimize both verbal and written signouts. An AHRQ WebM&M perspective discussed the current knowledge base regarding safe transitions of care for inpatients.
Ziaeian B, Araujo KLB, Van Ness PH, et al. J Gen Intern Med. 2012;27:1513-1520.
Medication discrepancies remain common at hospital discharge, despite intense efforts to improve medication reconciliation processes. Conducted in a geriatric patient population, this prospective cohort study found a similar incidence of medication discrepancies at discharge compared with prior studies, but concerningly, patients were unaware of most of these errors. Both provider errors and patient misunderstanding occurred more frequently for medications prescribed for conditions other than the primary hospital diagnosis, indicating that disease-specific efforts to improve medication safety may miss many errors.
Bradley EH, Curry LA, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-14.
Patients hospitalized for acute myocardial infarction (AMI) or congestive heart failure (CHF) are more likely to require hospital readmission within 30 days of discharge. Intensive efforts are underway to reduce readmissions in these patients, spurred by federal policies that penalize hospitals with excess readmission rates. However, this survey of nearly 600 hospitals found widely varying implementation of specific strategies to decrease readmissions in these patients, despite nearly all hospitals having declared reducing AMI and CHF readmissions to be a priority. The authors acknowledge that a lack of evidence supporting strategies to reduce readmissions, as well as variability in the underlying causes of readmissions between hospitals, may have influenced which interventions were implemented at different hospitals.
Lovig KO, Horwitz LI, Lipska K, et al. Jt Comm J Qual Patient Saf. 2012;38:403-407.
A retrospective chart review revealed that approximately 1 in 8 patients with diabetes was discharged without any antihyperglycemic therapy following acute myocardial infarction. Almost 90% of these omissions lacked justification, suggesting widespread errors in medication reconciliation.