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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 74 Results
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

Stolldorf DP, Ridner SH, Vogus TJ, et al. Implement Sci Commun. 2021;2:63.
Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
O'Leary KJ, Manojlovich M, Johnson JK, et al. Jt Comm J Qual Patient Saf. 2020;46:667-672.
Teamwork is essential to providing high quality, safe healthcare. This survey of general medicine nurses, nurse assistants, and physicians at four hospitals identified significant differences in perceptions of teamwork climate and collaboration across professional categories. While a majority of physicians reported the quality of collaboration with nurses as high, less than half of nurses gave high ratings to the quality of collaboration with physicians. Future teamwork training efforts should target the discrepancy in perceived teamwork across professional categories.
Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Cohen SP, Baber ZB, Buvanendran A, et al. Pain Med. 2020;21:1331-1346.
To address a need for national guidance on pain management practices during the COVID-19 pandemic, a panel including pain management experts from the military, Veterans Health Administration, and academia was convened. The proposed framework includes guidance for pain practitioners and institutions to balance risk mitigation for both providers and patients, staffing plans to prevent or minimize exposure of staff and patients, use of telehealth for pain management, conservation of resources, and access to pain management services. Any pain management plan must consider many facets including patients’ clinical circumstances and providers’ wellbeing.
Williams SC, Schmaltz SP, Castro GM, et al. Jt Comm J Qual Patient Saf. 2018;44:643-650.
The Joint Commission identifies inpatient suicide as a sentinel event. Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly in psychiatry wards. Researchers examined two national databases to develop the first data-driven appraisal of hospital suicide rates. Nationally, between 49 and 65 hospital suicides occur each year. Nearly 75% happen during psychiatric treatment, and the most common means of death is hanging. This hospital suicide rate is an order of magnitude lower than prior estimates. An accompanying editorial raises concerns about the much larger epidemic of suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies to reduce hospital suicide risk.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
O'Leary KJ, Johnson J, Manojlovich M, et al. Jt Comm J Qual Patient Saf. 2017;43:573-579.
Previous studies have investigated the benefits of unit-based interventions as a potential safety strategy. This survey study sought to examine implementation of several unit-based initiatives to improve care quality in inpatient settings: localization of physicians to specific designated units, nurse–physician joint leadership, periodic review of local performance data, and interdisciplinary rounds. Investigators invited residency program directors and hospital medicine leaders to participate in the study. The response rate was low and thus the findings may not reflect academic hospitals in general. Overall, among respondents' institutions, the interventions were not widely or consistently implemented. These findings underscore the challenge of translating interventions shown to be effective for enhancing safety in research settings into clinical practice.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43:433-447.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Burke RE, Schnipper JL, Williams M, et al. Med Care. 2017;55:285-290.
This retrospective cohort study demonstrated that a readmission risk score could prospectively identify patients at risk for readmissions for the four target conditions for nonpayment: acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure. These results suggest that this algorithm can identify a high-risk patient group who may benefit from interventions to prevent readmission.
Perspective on Safety February 1, 2017
… of teamwork, team training, and patient safety. … David P. Baker, PhD … Executive Vice President Center for Research, … BMJ Qual Saf. 2013;22:425-434. [go to PubMed] … David … Heidi … James … Baker … King … Battles … P … B … …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.
Greysen R, Harrison JD, Kripalani S, et al. BMJ Qual Saf. 2017;26:33-41.
Hospitals with high readmission rates face reductions in Medicare reimbursements. Understanding the patient perspective at the time of readmission may better inform future readmission reduction efforts. Researchers surveyed patients readmitted to the general medicine services within 30 days of discharge across 12 hospitals on multiple aspects of self-care. Although 91% of patients reported understanding of their discharge plan, more than 52% reported difficulty with at least one aspect of self-care after discharge.
Broman KK, Kensinger C, Hart H, et al. BMJ Qual Saf. 2017;26:30-32.
This observational study compared nurse–physician communication on two units, one in which the physicians called a stationary phone on the unit and a receptionist located the nurse and the other in which nurses carried mobile phones. The study team found no statistically significant difference in communication-related disruptions in patient care, but they did conclude that communication was more reliable when nurses carried mobile phones, as expected.
Schaefer EW, Williams M, Zee PC. J Hosp Med. 2012;7:489-96.
Given that hospitalized patients require 24-hour access to clinicians, management of fatigue due to shift work is an important consideration for overnight care teams. Discussing the physiological impacts of working during typical sleep time, or circadian misalignment, this review explores on-site naps, appropriate caffeine intake, and light exposure as techniques hospitalists can utilize to manage the negative effects associated with sleep disruption. A PSNet perspective described how fatigue can affect physician performance.
Bell SP, Schnipper JL, Goggins K, et al. J Gen Intern Med. 2016;31:470-477.
This randomized controlled trial at two academic medical centers studied the potential benefits of providing pharmacist medication reconciliation and counseling, along with individualized telephone follow-up after discharge, for adult patients hospitalized with acute coronary syndrome or acute decompensated heart failure. This extensive intervention did not reduce readmissions or emergency department visits within 30 days of discharge, though there was a small positive effect seen in patients with low health literacy.