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.
Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;Epub Aug 11.
Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).
Sterling MR, Lau J, Rajan M, et al. J Am Geriatr Soc. 2023;71:810-820.
Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).
Goyal P, Kneifati-Hayek J, Archambault A, et al. JACC Heart Fail. 2019;8:25-34.
Various potentially inappropriately prescribed medications can exacerbate heart failure (HF) and lead to adverse outcomes. This study examined patterns of prescribing HF-exacerbating medications for Medicare beneficiaries 65 years old and older, between 2003 and 2014, at admission to hospital for HF, at discharge from same and in between. Among 558 individuals, the numbers of HF-exacerbating medications remained the same or increased for 31% of them. Harmful prescribing practices were most strongly associated with small hospital size and patients with diabetes. The authors call for development of strategies to improve prescribing practices for heart failure patients.
Kaushal R, Kern LM, Barrón Y, et al. J Gen Intern Med. 2010;25.
Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.