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 21 Results

Identification of patient safety threats in a post-intensive care clinic.

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Karlic KJ, Valley TS, Cagino LM, et al. Am J Med Qual. 2023;38:117-121.

Because patients discharged from the intensive care unit (ICU) are at increased risk of readmission and post-ICU adverse events, some hospitals have opened post-ICU clinics. This article describes safety threats identified by post-ICU clinic staff. Medication errors and inadequate medical follow-up made up nearly half of identified safety threats. More than two-thirds were preventable or ameliorable.

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Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. J Pharm Pract. 2023;36:357-369.

Older adults are particularly vulnerable to medication-related safety events. This systematic review including 21 studies on medication-related problems in in older adults identified several types of safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead to poor outcomes among older adults in nursing homes, inpatient care, and community settings. The authors found the classes of medication related problems are similar to studies from a decade ago, suggesting that more intensive monitoring is needed.

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

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WebM&M Case March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done.

Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital.

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Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.

The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

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DeCherrie LV, Leff B, Levine DM, et al. Jt Comm J Qual Patient Saf. 2022;48:180-184.

Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.

Patient safety incidents describing patient falls in critical care in North West England between 2009 and 2017.

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Thomas AN, Balmforth JE. J Patient Saf. 2021;17:e71-e75.

Patient falls represent a serious source of preventable harm. The authors reviewed patient safety incidents in critical care units in England between 2009 and 2017 and found that a small proportion (2%) involved a fall. Common factors involved in fall incidents included patients attempting tasks without assistance, patient confusion, and staff being away from the patient. Harm to patient or staff occurred in 22% of falls.

Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients.

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Patient Safety Innovation April 7, 2021

The Hospital at Home^sm program provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions that are common among seniors. Studies have shown that the Hospital at Home program results in lower length of stay, costs, readmission rates, and complications than does traditional inpatient care, and surveys indicate higher levels of patient and family member satisfaction than with traditional care.

Making Healthcare Safer III Report

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Perspective on Safety March 30, 2020

This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.

In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD

Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.

Delirium in hospitalized older adults.

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Marcantonio ER. N Engl J Med. 2017;377:1456-1466.

Delirium is considered a patient safety problem that can be prevented with specific care practices in the hospital. This commentary reviews an incident involving a patient with delirium and describes evidence-based practices to manage the condition, such as avoiding medications that precipitate confusion, maintaining an environment that fosters orientation (light during the day, dark at night), and use of low-dose antipsychotic medications on a short-term basis if nonpharmacological approaches fail. The authors emphasize the importance of timely diagnosis and treatment of delirium.

Mismanagement of Delirium

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WebM&M Case May 1, 2016

An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.

The overlooked danger of delirium in hospitals.

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Hshieh TT, Yue J, Oh E, et al. JAMA internal medicine. 2015;175:512-20.

Delirium is a common unintended consequence of hospitalization, most often following a surgical procedure. This magazine article discusses characteristics of the condition, contributing factors, challenges to diagnosing it, and strategies to reduce its incidence. A previous AHRQ WebM&M commentary describes the key diagnostic differences between delirium and dementia.

Medication Reconciliation With a Twist (or Dare We Say, a Patch?)

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WebM&M Case May 1, 2014

An elderly woman with a history of dementia underwent surgical resection of new colon cancer, which relieved a bowel obstruction. She developed acute delirium postoperatively, and the team discovered they had neglected to capture her cholinesterase inhibitor patch (a medication for dementia) in the official medication reconciliation list.

In-facility delirium programs as a patient safety strategy: a systematic review.

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Reston JT, Schoelles KM. Ann Intern Med. 2013;158:375-80.

Several types of interventions are effective at preventing the development of delirium in hospitalized patients, according to this review conducted as part of the AHRQ Making Health Care Safer II report. Key components of successful interventions included pain management, sleep enhancement, and early mobilization and nutrition. The consequences of a missed delirium diagnosis are discussed in an AHRQ WebM&M commentary.

Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit

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Perspective on Safety December 1, 2012

This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.

In Conversation With… Sharon K. Inouye, MD, MPH

A leading expert in geriatrics research and innovation, Dr. Inouye developed and validated a widely used tool, the Confusion Assessment Method (CAM), to identify delirium.

The Safety and Quality of Long Term Care

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WebM&M Case September 1, 2011

Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

In-home medication reviews: a novel approach to improving patient care through coordination of care.

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Willis JS, Hoy RH, Jenkins WD. J Community Health. 2011;36:1027-31.

This study found that trained undergraduate student volunteers were able to complete important medication reviews for patients as part of an in-home outreach program.

Improvement Cymru.

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NHS Wales.

This national program draws from other large collaborative efforts to engage health care organizations across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018.

Delirium or Dementia?

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WebM&M Case May 1, 2009

An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.

Chronic kidney disease adversely influences patient safety.

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Seliger SL, Zhan M, Hsu VD, et al. J Am Soc Nephrol. 2008;19:2414-9.

This study found that patients with chronic kidney disease experienced more hospital adverse events as measured by AHRQ Patient Safety Indicators (PSIs). Similar to past research, the findings highlight the potential for specific preventive strategies that may benefit this patient population.

Iatrogenic delirium and coma: a "near miss."

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Dunn WF, Adams SC, Adams RW. Chest. 2008;133:1217-20.

This case report describes how diagnostic and medication errors led to a temporary coma. The article features the views of both the patient and her husband, and an accompanying editorial discusses disclosing errors to patients.

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