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.
Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.
Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Manias E, Bucknall T, Hughes C, et al. BMC Geriatr. 2019;19:95.
… BMC Geriatr … BMC Geriatr … Transitions of care represent a vulnerable time for patients. Older adults in particular may experience a variety of challenges related to such transitions, … patients during care transitions. … Manias E, Bucknall T, Hughes C, Jorm C, Woodward-Kron R. Family involvement in …
This retrospective cohort study of patients age 65 and older on chronic medications found that unintentional medication discontinuation does occur following hospitalization. As with prior studies, medication documentation in hospital discharge summaries remains highly variable.
… at the time of hospital discharge , most of which involved a pharmacist-mediated intervention. Overall, there was no … either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in …
Barry E, O'Brien K, Moriarty F, et al. BMJ Open. 2016;6:e012079.
Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.
Hume AL, Quilliam BJ, Goldman R, et al. BMJ Qual Saf. 2011;20:875-84.
This study describes the development of improved alerts and alternate treatment algorithms to reduce the number of adverse drug events associated with potentially inappropriate medication use in the elderly.
Hughes C, Lapane KL. Int J Qual Health Care. 2006;18:281-6.
… Research and Quality (AHRQ)–supported study discovered a need to better address safety culture in nursing homes, drawing on findings from a self-reported survey. Investigators surveyed more than 360 …
Lapane KL, Hughes C, Daiello LA, et al. J Am Geriatr Soc. 2011;59:1238-45.
An information technology–based intervention, which identified nursing home patients at high risk for adverse drug events and recommended customized management strategies, successfully reduced the risk of delirium.