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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 23 Results
White A, Fulda KG, Blythe R, et al. Expert Opin Drug Saf. 2022;21:1357-1364.
Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.
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 … common cause of medication harm. … Paradissis C, Cottrell N, Coombes I, et al. Patient harm from cardiovascular …
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.
Andrade AQ, Roughead EE. Med J Aust. 2019;210:S24-S27.
Despite concerns regarding reliability, consumer-facing health technologies have the potential to improve diagnosis, patient engagement, and patient–clinician communication. This commentary suggests that research and clinician engagement are required in the development of consumer-focused medication management applications to support the safe use of these tools.
Reeve E, Wolff JL, Skehan M, et al. JAMA Intern Med. 2018;178:1673-1680.
Deprescribing or stopping unnecessary medications is an important strategy for reducing medication-related harm in older adults. A group of 1981 Medicare beneficiaries reported broad support (92%) for stopping at least one of their medications if their clinician determined it was safe. A WebM&M commentary provides in-depth recommendations to achieve safe prescribing in older patients.
Falconer N, Barras M, Martin J, et al. Eur J Clin Pharmacol. 2019;75:137-145.
Lack of clarity around language used to discuss patient safety concepts hinders effective monitoring and measurement of errors and their impact. This narrative review examined the various terms used to discuss medication-related harm. The authors advocate for development of standard definitions and terms for use in medication error research, policy development, and improvement efforts.
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 …
Reeve E, Moriarty F, Nahas R, et al. Expert Opin Drug Saf. 2017;17:39-49.
Deprescribing has been recommended as a way to reduce polypharmacy. This review examines safety concerns associated with deprescribing among older patients and offers strategies to reduce risks. The authors suggest that further research is needed to understand potential harms of deprescribing and highlight the importance of shared decision-making to improve the safety of this process.
McCaffery KJ, Jansen J, Scherer LD, et al. BMJ. 2016;352:i348.
Medical care overuse can lead to countless direct and indirect harms. This commentary explores challenges to communicating risks associated with overdiagnosis and overtreatment to consumers and describes strategies including patient decision aids and initiatives like the the Choosing Wisely campaign.
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 …
Perspective on Safety March 1, 2015
… (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. … Ian Scott, 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.