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.
Malevanchik L, Wheeler M, Gagliardi K, et al. Jt Comm J Qual Patient Saf. 2021;47:775-782.
Communication in healthcare is essential but can be complicated, particularly when there are language barriers between providers and patients. This study evaluated a hospital-wide care transitions program, with a goal of universal contact with discharged patients to identify and address care transition problems. Researchers found that the program reached most patients regardless of English proficiency, but that patients with limited English proficiency experienced more post-discharge issues, such as difficulty understanding discharge instructions, medication concerns and follow-up questions, and new or worsening symptoms.
This editorial discusses how adverse events can occur if standardized order sets in computerized provider order entry systems are based on outdated or equivocal evidence. The authors outline a process for ensuring order sets and decision support systems contain current and valid evidence in order to maximize their effectiveness and minimize risk to patients. The editorial is based on a case described in the related article.
Lin CA, Shah K, Mauntel LCC, et al. Am J Health Syst Pharm. 2018;75:153-158.
Errors in medication delivery can result in patient harm. This commentary introduces use of drones as a way to improve patient access to medications. The authors outline regulatory and safety factors that stakeholders seeking to utilize drone technology should consider.
Diagnostic error has gained recognition as a contributor to patient harm. This commentary explores physician diagnostic calibration—the relationship between individual confidence in diagnostic decision making and diagnostic accuracy—including factors that influence it.