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.
Exploring the literature on efforts to reduce medication errors in hospitalized children, this systematic review examined five interventions, including introduction of computerized provider order entry systems, clinical pharmacist participation in the frontline care team, and implementation of barcode medication administration systems. Although the interventions showed some success, none of the studies found a significant reduction in patient harm.
Smeulers M, Lucas C, Vermeulen H. Cochrane Database of Syst Rev. 2014;6:CD009979.
Incomplete handoffs and poor communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This systematic review sought to determine effective interventions to enhance nursing handoffs. Although several studies have examined handoff techniques that nurses used, there is no evidence to indicate whether verbal handoffs, chart-based handoffs, or handoffs including patients or family are associated with improved patient outcomes, echoing a prior systematic review. The authors recommend that nursing handoffs be structured, include face-to-face communication, involve patients, and utilize health information technology. They also call for studies to compare different approaches in order to achieve an evidence-based best practice. A past AHRQ WebM&M commentary describes the consequences of an incomplete nursing handoff.
Verweij L, Smeulers M, Maaskant JM, et al. J Nurs Scholarsh. 2014;46:340-8.
This study used direct observation and interviews to evaluate the effectiveness of tabards, do-not-disturb signs worn by registered nurses dispensing medications in inpatient settings, in preventing disruptions. The authors found a decrease in interruptions and medication errors, suggesting that tabards may augment safety despite controversy regarding their use.