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.
Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.
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.
Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.
Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.
Premature diagnostic closure, also called anchoring bias, relies on initial diagnostic impression without continuing to explore differential diagnoses. This commentary proposes a cognitive forcing strategy of “endpoint diagnosis,” or continuing to ask “why” until additional diagnostic evaluations have been exhausted. The authors describe four common contexts when endpoint diagnoses are not pursued or reached.
Reeve J, Maden M, Hill R, et al. Health Technol Assess. 2022;26:1-148.
Deprescribing is a strategy to reduce potential harms associated with polypharmacy. This scoping review synthesized the evidence about how physicians and patients feel about deprescribing and how deprescribing can be done safely. Shared decision making was identified as an essential component for building trust in the process and for keeping it patient-centered.
… ten studies assessing symptom checkers evaluating a variety of conditions, including infectious diseases and … of symptom checkers varies and has low accuracy. … Wallace W, Chan C, Chidambaram S, et al. NPJ Digit Med. …
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.
Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;31:716-724.
… to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were … early warning system implemented to reduce adverse events: a qualitative study. BMJ Qual Saf. Epub 2022 Apr 15. …
Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.
Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;30:977-985.
… BMJ Qual Saf … Diagnostic error continues to be a source of preventable patient harm. The authors undertook a … of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, … policy changes, should be multipronged. … Cheraghi-Sohi S, Holland F, Singh H, et al. Incidence, origins and avoidable …
Bhasin S, Gill TM, Reuben DB, et al. N Engl J Med. 2020;383:129-140.
This study randomized primary care practices across ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury, which included risk assessment and individualized plans administered by specially trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care.
Dennerlein JT, Burke L, Sabbath EL, et al. Hum Factors. 2020;62:689–696.
The authors reviewed emerging workplace recommendations for reducing workers’ exposures to COVID-19 and, using human factors and ergonomic principles, proposed an approach for supporting worker safety, health and well-being during the pandemic. The recommended approach includes six key characteristics: (1) leadership commitment; (2) policies, programs and practices fostering supportive working conditions; (3) stakeholder participation at every level of the organization; (4) comprehensive and collaborative strategies; (5) adherence to state and federal regulations, as well as ethical norms, and; (6) commitment to data-driven change and continuous improvement.
Ward M, Shé ÉN, De Brún A, et al. BMC Med Edu. 2019;19:232.
… more prevalent in health care. This article describes a "serious game" PlayDecide for use of multidisciplinary … perspectives and information, then working towards a shared group policy position around error reporting and … in two large urban academic medical centers and noted a significant change in error reporting behavior among junior …
King L, Peacock G, Crotty M, et al. Health Expect. 2019;22:385-395.
Patients and families have the potential to help medical teams proactively detect clinical deteriorations. This qualitative study with consumer advocates resulted in a comprehensive model for empowering patients to accurately activate rapid response systems.
Trent M, Dooley DG, Dougé J, et al. Pediatrics. 2019;144:e20191765.
Children and adolescents are particularly vulnerable to systemic weaknesses in health care. This guidance examines the impact of racism and implicit biases on pediatric patients. The policy summarizes the evidence on institutionalized racism and health to motivate the adoption of strategies to reduce that impact at the system and organizational level.
Manaseki-Holland S, Lilford RJ, Te AP, et al. Milbank Q. 2019;97:228-284.
… examined whether preventable death rates could be used as a measure of hospital quality. Researchers reviewed 23 … authors conclude that preventable death rates would not be a valid or reliable measure of patient safety . A past PSNet interview discussed the development of hospital …
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
… adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have … from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to … half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria . The …