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.
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 …
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.
Scott IA, Pillans PI, Barras M, et al. Ther Adv Drug Saf. 2018;9:559-573.
The prescribing of potentially inappropriate medications is a quality and safety concern. This narrative review found that information technologies equipped with decision support tools were modestly effective in reducing inappropriate prescribing of medications, more so in the hospital than the ambulatory environment.
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.
Poudel A, Peel NM, Nissen L, et al. Ann Pharmacother. 2014;48:1425-33.
… aged 70 and older who were discharged from the hospital to a long-term care facility were prescribed a medication deemed to be high risk according to Beers …
Brand CA, Tropea J, Gorelik A, et al. Int J Qual Health Care. 2012;24:266-78.
This study found high levels of physician agreement using an adverse event screening tool for patients admitted with chronic heart failure and pneumonia.