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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 - 7 of 7 Results
Kirwan G, O’Leary A, Walsh C, et al. Eur J Hosp Pharm. 2023;30:86-91.
Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.
Kelly D, Koay A, Mineva G, et al. Public Health. 2022;214:50-60.
Natural disasters and other public health emergencies (PHE), such as the COVID-19 pandemic, can dramatically change the delivery of healthcare. This scoping review identified considerable research examining the relationship between public health emergencies and disruptions to personal medication practices (e.g., self-altering medication regimens, access barriers, changing prescribing providers) and subsequent medication-related harm.
Redmond P, McDowell R, Grimes TC, et al. BMJ Open. 2019;9:e024747.
This retrospective cohort study of patients age 65 and older on chronic medications found that unintentional medication discontinuation does occur following hospitalization. As with prior studies, medication documentation in hospital discharge summaries remains highly variable.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Redmond P, Grimes TC, McDonnell R, et al. Cochrane Database Syst Rev. 2018;8:CD010791.
This systematic review identified 25 randomized controlled trials of methods to improve medication reconciliation at the time of hospital discharge, most of which involved a pharmacist-mediated intervention. Overall, there was no clear evidence that medication reconciliation interventions reduced either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in implementing effective medication reconciliation programs in real-world settings.
Barry E, O'Brien K, Moriarty F, et al. BMJ Open. 2016;6:e012079.
Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.
Grimes TC, Duggan CA, Delaney TP, et al. Br J Clin Pharmacol. 2011;71:449-57.
Medication errors at hospital discharge remain a persistent problem, as no consensus exists on the best method of medication reconciliation. This study analyzed the patient- and medication-specific factors associated with medication reconciliation discrepancies upon discharge from two Irish hospitals.