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.
… E. Lynn College of Nursing Florida Atlantic University … AliceBonner, PhD, GNP … Associate Professor, School of Nursing … Raton, FL: Florida Atlantic University. [Available at] 10. Tjia J, BonnerA, Briesacher BA, McGee S, Terrill E, Miller …
Field T, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-7.
… This study adopted the SBAR communication tool as part of a protocol to improve the quality of warfarin management in the nursing home setting. Using a facilitated telephone communication between nurses and … significant improvements in their therapeutic levels and a non-statistically significant reduction in adverse events. …
Fischer SH, Tjia J, Field T. J Am Med Inform Assoc. 2010;17:631-6.
Failure to follow up on test results has been linked to missed and delayed diagnoses in the ambulatory setting. Although electronic health records (EHR) hold great promise for addressing this issue, this systematic review found only modest published evidence linking EHR use to improved laboratory test monitoring. This finding corroborates other studies documenting persistent failure to comprehensively follow up abnormal lab tests and radiologic studies despite use of an EHR. The authors conclude that further research will be required to develop optimal test management systems within electronic medical records.
Tjia J, Field T, Garber LD, et al. Am J Manag Care. 2010;16:489-96.
This study reports on the development of standards for laboratory monitoring of high-risk medications (such as anticoagulants) in ambulatory care. Pilot testing revealed that the developed guidelines were not being consistently followed, with infrequently prescribed medications most likely to be monitored inappropriately.
Tjia J, Mazor KM, Field T, et al. J Patient Saf. 2009;5:145-152.
… the need to use structured communication protocols as a means of improving communication. Patient harm can result from a physician's failure to acknowledge a nurse's concerns about patients, as illustrated in this …
Tjia J, Bonner A, Briesacher BA, et al. J Gen Intern Med. 2009;24:630-5.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to medication errors, as they are often elderly, have multiple chronic illnesses, and take multiple medications. In this study, medication discrepancies (among the hospital discharge summary, SNF referral form, and SNF admission orders) were the rule rather than the exception. Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants, and hypoglycemic agents, which have been linked to serious medication errors in elderly patients. While The Joint Commission has mandated medication reconciliation for long-term care facilities as part of the 2009 National Patient Safety Goals, the authors note that many SNFs do not maintain Joint Commission accreditation, implying that state or national regulations may be needed to improve medication safety across the hospital–SNF transition.
Field TS, Mazor KM, Briesacher BA, et al. J Am Geriatr Soc. 2007;55:271-276.
This cohort study, conducted within a large health management organization (HMO), examined the frequency of adverse drug events (ADEs) that were attributable to errors elderly patients made in handling their medications. Nearly one-quarter of ADEs were caused by patient error, most often due to failure to administer the medication at the proper dose or failure to follow the clinician's instructions on medication use. The classes of medications most frequently associated with errors (hypoglycemics, anticoagulants, and cardiovascular medications) were similar to those found in prior research. A previous commentary discussed the role of preventable and non-preventable patient errors in contributing to adverse clinical outcomes.