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.
Incidence of maternal harm is increasing in the United States. This news article series reports on factors that contribute to preventable maternal mortality, such as omission of recommended care processes, lack of patient-centeredness, and missed or delayed diagnoses of serious conditions.
This news article discusses problems associated with nurse fatigue and strategies hospitals are utilizing to prevent nursing staff from being overtired, such as paying nurses for scheduling flexibility and employing buddy systems to check each other's work.
Gandara E, Moniz T, Ungar J, et al. J Hosp Med. 2009;4.
Documentation of important care transition information, such as medication changes and pending test results, was often lacking when patients were transferred from a hospital to a rehabilitation facility.
El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-8.
Less than 20% of ambulatory practices in the United States utilize electronic health records (EHRs). Uptake has been limited by cost issues and concern about the impact of EHRs on clinician workflow. This survey evaluated clinicians' perceptions of a newly implemented electronic medical record in three primary care clinics. Although initially clinicians felt that the EHR resulted in longer patient visits and increased the time spent documenting, by 1 year after implementation, clinicians felt that the EHR improved their ability to follow up on test results and communicate with other providers, and contributed to higher quality care overall. Importantly, these perceived advantages emerged only after 1 full year of using the new system.
Gandara E, Moniz TT, Ungar J, et al. Jt Comm J Qual Patient Saf. 2008;34:460-3.
Many patients discharged from hospitals on anticoagulant medications (including warfarin and heparin) lacked adequate documentation of the duration of therapy and monitoring needs. Ensuring the safety of anticoagulant therapy is a Joint Commission National Patient Safety Goal.
The researchers performed a comparative cost analysis between a paper-based medication ordering and administration process and an electronic system and found that the online system had the potential to cut costs and reduce adverse drug events.