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The PSNet Collection: All Content

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.

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Displaying 1 - 20 of 24 Results
Kane‐Gill SL, Wong A, Culley CM, et al. J Am Geriatr Soc. 2020;69:530-538.
… (ADEs) in older adults . This study assessed the impact of a pharmacist-led, patient-centered telemedicine program to … program experienced fewer adverse drug events compared to a usual care group. This innovative model has the potential … errors in nursing home residents. … Kane- Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen …
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.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Hebbar KB, Colman N, Williams L, et al. Simul Healthc. 2018;13:324-330.
Medication administration errors are common and costly, especially for children. Investigators conducted a multipronged quality improvement intervention for pediatric medication administration. First, they implemented a one-time simulation training for pediatric bedside nurses across emergency department, hospital ward, and intensive care settings to foster use of standardized medication administration best practices. They observed bedside nursing via audits for 18 months of follow-up. Adherence to best practices improved from 51% of medication administration instances to 84%, and the rate of medication administration errors declined significantly. The authors suggest that simulation training is an effective strategy to improve the safety of pediatric medication administration.
Anderson AM, Matsumoto M, Saul MI, et al. JAMA Dermatol. 2018;154:569-573.
Diagnostic errors among physician extenders are understudied, especially in subspecialty settings. In this study, physician assistants working in dermatology clinics performed more biopsies and diagnosed fewer skin cancers and melanoma than board-certified dermatologists. The authors were unable to assess how often either clinician type missed diagnoses of skin cancer.
Kane-Gill SL, Achanta A, Kellum JA, et al. World J Crit Care Med. 2016;5:204-211.
Medication administration technologies can help collect data to enhance processes and reduce medication errors. This commentary discusses how organizations are using clinical decision support systems to track problems and incorporating different data sets to prevent adverse drug events.
Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.
Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.
Smith KJ, Handler S, Kapoor WN, et al. Am J Med Qual. 2016;31:315-22.
Medication inconsistencies are common at hospital discharge. This study found that computerized discharge medication reconciliation, combined with automatic communication of the reconciled medication list to the patient's primary care physician, reduced discharge medication errors.
Castle NG, Wagner LM, Ferguson J, et al. Journal of Applied Gerontology. 2012;33.
In this study, nursing homes that received hand hygiene deficiency citations were more likely to have low staffing levels or to have received other citations for poor quality of care.
McKibbon A, Lokker C, Handler S, et al. J Am Med Inform Assoc. 2012;19:22-30.
This systematic review identified 87 randomized controlled trials assessing the effect of information technology on various aspects of medication safety, including studies of computerized provider order entry. Although processes of care consistently improved, few studies demonstrated improvement in clinical outcomes.
Castle NG, Wagner LM, Ferguson JC, et al. Health Care Manage Rev. 2011;36:175-187.
… Rev … Managers and nursing directors at nursing homes had a generally positive impression of institutional safety … were less favorable. … Castle NG, Wagner LM, Ferguson JC, Handler SM. Safety culture of nursing homes: opinions of top …