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.
Korenstein D, Harris RP, Elshaug AG, et al. J Gen Intern Med. 2021;36:2105-2110.
Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.
Paradissis C, Cottrell N, Coombes ID, et al. Ther Adv Drug Saf. 2021;12:204209862110274.
… Ther Adv Drug Saf … Adverse drug events are a common source of harm in both inpatient and ambulatory … 75 studies concluded that cardiovascular medications are a leading cause of medication harm across different clinical …
Chalmers K, Gopinath V, Brownlee S, et al. JAMA Health Forum. 2021;2:e211719.
Overuse or low-value procedures may result in patient physical, psychological, or emotional harm. This study explored the association between eight low-value care procedures and length of stay (LOS) and cost. All eight procedures were associated with increased LOS and cost, particularly spinal fusion. Patients receiving low-value care may be exposed to increased risk of adverse events and hospital-acquired conditions.
Scott IA, Hubbard RE, Crock C, et al. Intern Med J. 2021;51:488-493.
Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51:520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.
Chalmers K, Smith P, Garber J, et al. JAMA Netw Open. 2021;4:e218075.
Overtreatment and overuse of healthcare services have been identified as potential sources of patient harm. Using Medicare fee-for-services claims, this study sought to describe hospital characteristics associated with 12 low-value services. Results showed the highest levels of overuse were associated with nonteaching and for-profit hospitals, particularly in the American South. The authors suggest interventions to decrease overuse and overtreatment could be targeted based on hospital characteristics and region.
Badgery-Parker T, Pearson S-A, Dunn S, et al. JAMA Intern Med. 2019;179:499-505.
… study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed … condition. … Badgery-Parker T, Pearson SA, Dunn S, Elshaug AG. Measuring Hospital-Acquired Complications …
Scott IA, Campbell DA. Med J Aust. 2018;208:196-197.
… the effort to improve diagnosis have heralded diagnosis as a team activity . This commentary suggests that specialists … rather than disease-centered care to ensure a wide range of considerations are explored to avoid …
Scott IA, Hilmer SN, Reeve E, et al. JAMA Intern Med. 2015;175:827-34.
… … JAMA Intern Med … Polypharmacy in older patients is a predictor of medication errors. However, deprescribing—stopping or reducing medicines in a patient's drug regimen—can introduce opportunities for harm if not done appropriately. This commentary presents a protocol to enhance the safety of deprescribing by …
… (SHMI)—is one such measure. The commonly used HSMR is a ratio of the observed number of in-hospital deaths to the … means for identifying and responding to unsafe care. … IanScott, MBBS, MHA, MEd … Director of Internal Medicine and …
This piece discusses risk-adjusted hospital mortality rates as a measure of hospital safety, including why they've become popular, major flaws such as low sensitivity, and alternative ways to use them.
Sir Brian Jarman designed the methodology for hospital standardized mortality ratios, a widely used method of measuring quality and safety, and was involved with the Bristol Royal Infirmary Inquiry. We spoke with him about the development of the HSMR and their role in monitoring performance.
Anderson K, Stowasser D, Freeman C, et al. BMJ Open. 2014;4:e006544.
This systematic review examined prescribing of potentially inappropriate medications and found that prescriber characteristics (such as clinical inertia and lack of knowledge) and system characteristics (such as insufficient time to review medications and limited availability of nonmedication treatments) both contributed to persistent prescribing of medications associated with increased risks. These findings emphasize the need for fundamental health care reform in order to improve medication safety.