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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 35 Results
Starmer AJ, Spector ND, O'Toole JK, et al. J Hosp Med. 2023;18:5-14.
I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.
Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Dager WE, Ansell J, Barnes GD, et al. Jt Comm J Qual Saf. 2020;46:173-180.
The Joint Commission previously issued a sentinel event alert for medication errors relating to anticoagulant therapies and included them as part of the National Patient Safety Goal (NPSG) program. This commentary discusses the eight 2019 NPSGs for anticoagulants: dosing protocols; anticoagulant reversal; perioperative management; laboratory monitoring; anticoagulant safety; patient education; unit dose packaging, and; programmable pumps.  
Brenner AT, Malo TL, Margolis M, et al. JAMA Intern Med. 2018;178:1311-1316.
Shared decision making (SDM) between clinicians and patients is an integral part of developing true patient-centered care. The principles of SDM are broadly applicable to most clinician–patient encounters, but they may be particularly important in making decisions where the risks and benefits to an individual patient are nuanced. One such example is screening for lung cancer using low-dose computed tomography (LDCT), which may benefit certain patients but also poses a risk of harm due to overdiagnosis. The Centers for Medicare and Medicaid Services mandates SDM using a formal decision aid for reimbursement for lung cancer screening. However, this analysis of transcribed conversations between physicians and patients found almost no use of SDM principles. In particular, physicians universally recommended screening with LDCT, failed to discuss the potential for overdiagnosis, and did not use decision aids or patient education materials. Although limited by a small sample size, this study raises the concern that structural barriers (such as lack of time with patients) and poor understanding of SDM may be exposing patients to harm through limited understanding of diagnostic testing decisions. A related commentary discusses the potential for overdiagnosis of lung cancer if LDCT is used without proper attention to SDM.
Simon SR, Keohane CA, Amato MG, et al. BMC Med Inform Decis Mak. 2013;13.
Effective use of computerized provider order entry (CPOE) has been hindered by limited information on how to properly implement these systems. This case study of CPOE at five community hospitals identifies the major resources needed for and factors associated with successful implementation.
Leung AA, Keohane C, Lipsitz S, et al. J Am Med Info Asso. 2013;20:e85-e90.
As more hospitals begin to implement computerized provider order entry (CPOE) systems, rigorously evaluating their real-world performance at preventing medication errors has become crucial. The Leapfrog Group was an early pioneer in calling for wider CPOE implementation, and this study reports on the validation of a tool developed by Leapfrog for assessing the ability of CPOE systems to prevent serious errors. The tool, which uses simulated cases, proved to be effective, as the incidence of errors it detected corresponded closely to the actual error rates of participating hospitals. Prior simulation research has shown that many commercial systems fail to detect even potentially serious errors, and this study provides reassurance that CPOE systems that pass the Leapfrog evaluation are likely to successfully prevent medication errors.
Huang SS, Septimus E, Kleinman K, et al. N Engl J Med. 2013;368:2255-2265.
Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This pragmatic, cluster-randomized trial to determine the most effective approach for reducing the rates of MRSA was implemented in 43 hospitals, including 74 ICUs and 74,256 patients. Compared to baseline, modeled hazard ratios for MRSA clinical isolates were 0.92 for those undergoing screening isolations, 0.75 for targeted decolonization, and 0.63 for universal decolonization. Universal decolonization resulted in significantly greater reduction in blood stream infections than the other two studied approaches for infection reduction.
Linsky A, Simon SR. BMJ Qual Saf. 2013;22:103-9.
Discrepancies between patients' recorded medication lists and the medications they were actually taking were very common in an ambulatory clinic with a fully integrated electronic health record. The study provides another example that electronic medical records alone are not a foolproof mechanism for preventing errors.
Schillig J, Kaatz S, Hudson M, et al. J Hosp Med. 2011;6:322-8.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.
Quinn MA, Wilcox A, Orav J, et al. Med Care. 2009;47:924-8.
This study found a positive relationship between being involved in quality improvement activities and physician work–life measures such as practice dissatisfaction, professional isolation, and work–life stress. The authors advocate for greater efforts to engage physicians in quality improvement work, as this may impact the quality of care delivered to their patients.