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.
The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Washington DC: US Department of Health and Human Services. October 2019.
Deprescribing has the potential to result in patient harm. This publication reviews considerations for physicians to safely discontinue or taper long-term opiate therapy. Elements of the guidance discuss assessment of risk, individualized care plans, shared decision making, and patient support as components of safe practice.
Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.
Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.
London, UK: Royal College of Surgeons of England; 2016.
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.
Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.
Langer T, Martinez W, Browning DM, et al. BMJ Qual Saf. 2016;25:615-25.
Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.
Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241510349.
Overuse of diagnostic imaging poses patient safety hazards, particularly for children. This report reviews techniques clinicians can use to discuss risks associated with using radiologic procedures with parents of pediatric patients. The publication includes answers to common questions about various types of tests and tips for enhancing conversations with parents.
Kaprielian VS; Sullivan DT; Josie King Foundation.
The experience of Sorrel King and the death of her daughter has motivated health care leaders and the industry to improve patient safety. This curriculum provides a set of materials that incorporates lessons from Josie's Story into existing educational programs.
Rutter P, Brown D, Howard J, et al. Drug Saf. 2014;37:465-9.
Pharmacists continue to play a critical role in reducing medication errors. Exploring ways to enhance the role of community pharmacists in medication safety, this commentary advocates for providing education about the importance of reporting adverse drug events and training to improve diagnostic skills.
Kemper PE, van Dyck C, Wagner C, et al. Jt Comm J Qual Patient Saf. 2014;40:311-318.
This Dutch study found that management support for overall safety efforts made it more likely that participants in teamwork training sessions would be able to translate these concepts into daily practice.
Nguyen H-T, Pham H-T, Vo D-K, et al. BMJ Qual Saf. 2014;23:319-24.
An educational program that included lectures, ward-based teaching sessions, and protocols significantly decreased the rate of intravenous medication errors in an intensive care unit in Vietnam. However, clinically significant errors still occurred in nearly half of all medication administrations (down from 64% pre-intervention).
O'Beirne M, Reid R, Zwicker K, et al. J Patient Saf. 2013;9:211-8.
This study estimated a cost of approximately CAD $260,000 over 4 years to develop and run a safety learning system for family physician clinics in Calgary, Alberta. Policy makers and payers may need to determine whether there is an adequate return on investment for the sustainability of these types of programs.
Kliger J, Singer SJ, Hoffman F, et al. Jt Comm J Qual Patient Saf. 2012;38:51-60.
While quality improvement projects can result in short-term, local success, ensuring the sustainability and spread of successful interventions can be extremely challenging. This follow-up study describes methods used to disseminate a successful project to reduce medication administration errors beyond the original pilot hospitals. The article details how stratiegies for communication, local adaptation, teamwork, and learning from failure were essential to implementing the intervention across a broad range of hospitals. This approach achieved sustained improvement in medication administration error rates in both the initial and subsequent groups of hospitals.
Lafata JE, Gunter MJ, Hsu J, et al. Med Care. 2007;45:966-72.
This randomized study found that academic detailing yielded modest impact on appropriate monitoring of patients started on selected high-risk medications. A past study also demonstrated limited success with academic detailing as a sole intervention to promote medication safety.
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