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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 - 9 of 9 Results
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.
Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;78:3745-3759.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.
Redley B, Taylor N, Hutchinson A. J Adv Nurs. 2022;78:3710-3720.
Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.
Redley B, Douglas T, Hoon L, et al. Int J Nurs Stud. 2022;127:104178.
Nurses have a significant impact on patient safety. This integrative review of clinical practice guidelines identified 6 themes representing nursing care strategies to manage risk and prevent harm – (1) detect risk or early change, (2) act early to prevent deterioration, (3) identify and treat underlying conditions, (4) grade escalation of care, (5) provide a safe care environment, and (6) engage patient and care partners. These findings highlight the complexity of nursing work and illustrate strategies that nurse leaders can integrate into local practice to improve safe care.
Mekonnen AB, Redley B, Courten B, et al. Br J Clin Pharmacol. 2021;87:4150-4172.
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.
McDerby N, Kosari S, Bail K, et al. J Clin Pharm Ther. 2019;44:595-602.
Medication errors are a common cause of preventable harm in long-term care. In this controlled pilot study, a pharmacist embedded in a long-term care facility was able to identify and intervene on potential medication problems, primarily by preventing inappropriate dosage form modification (i.e., crushing tablets or opening capsules to facilitate drug administration).
Redley B, Raggatt M. BMJ Qual Saf. 2017;26:704-713.
Standardized screening tools are frequently used to assess risk among hospitalized older patients to prevent harm from falls and adverse drug events. This mixed methods study of 11 health services across Victoria, Australia, found that skin integrity and fall risk were consistently assessed, but there was significant variability across institutions with regard to the assessment of nutrition, cognitive function, and medication issues.
Redley B, Bucknall T, Evans S, et al. Int J Qual Health Care. 2016;28:573-579.
Efforts to improve the safety of handoffs have focused on standardizing the signout process. In this mixed methods study, researchers observed 185 anesthetist-to-nurse handoffs from the operating room to the postanesthesia care unit across 3 hospitals. They then conducted focus groups to better understand aspects of safe handoff practices. This work led to the development of a more standardized handoff structure.