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.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.
Hodkinson A, Zhou, A, Johnson J, et al. BMJ. 2022;378:e070442.
Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.
Joseph K, Newman B, Manias E, et al. Patient Educ Couns. 2022;105:2778-2784.
… of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for … competence during implementation. … Joseph K, Newman B, ManiasE, et al. Engaging with ethnic minority consumers to improve safety in cancer services: a national stakeholder analysis. Patient Educ Couns. E pub …
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21:1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.
Newman B, Joseph K, Chauhan A, et al. Health Expect. 2021;24:1905-1923.
… systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and …
Manias E, Bucknall T, Hutchinson AM, et al. Expert Opin Drug Saf. 2021:1-19.
… Expert Opin Drug Saf … Medication errors are a common cause of preventable harm in long-term care … about decision making; and lack of provider training. … ManiasE, Bucknall T, Hutchinson A, et al. Resident and family …
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.
Mitchell G, Porter S, Manias E. J Adv Nurs. 2021;77:899-909.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.
Communication failures hinder safety of health care delivery and are particularly prevalent in medication errors. This review explores how interdisciplinary work can augment communication during medication processes and highlights interdisciplinary collaboration strategies such as pharmacist engagement in care teams.
Johnson M, Sanchez P, Langdon R, et al. J Nurs Manag. 2017;25:498-507.
Interruptions in nursing care are common and can contribute to errors. In keeping with prior research, this observational study of nurses found that interruptions in medication preparation and administration can compromise patient safety.
Walton MM, Harrison R, Kelly P, et al. BMJ Qual Saf. 2017;26:743-750.
This study elicited patients' reports of adverse events during hospitalization. Researchers found that 7% of hospitalized patients reported experiencing an adverse event and, consistent with prior studies, patients contributed unique contextual data to adverse event reporting.
Stevens KR, Engh EP, Tubbs-Cooley HL, et al. Res Nurs Health. 2017;40:197-205.
This prospective reporting study asked frontline nurse participants to record operational failures, or breakdowns in usual care processes, in the course of their usual work. Nurses recorded about six such failures per shift, suggesting that systems failures are common in acute care settings.
Riley W, Begun JW, Meredith L, et al. Health Serv Res. 2016;51:2431-2452.
Prior research has shown that reducing preventable perinatal harm leads to a decrease in malpractice claims. In this prospective study involving the perinatal units across 14 hospitals from 12 states and accounting for almost 350,000 deliveries, researchers found that successful implementation of 3 standard care processes resulted in a 14% decrease in harm in perinatal care from the baseline period.
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
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