Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 616 Results
Rapp T, Sicsic J, Tavassoli N, et al. Eur J Health Econ. 2023;24:1085-1100.
Potentially inappropriate prescribing in long-term care facilities increases the risk of adverse drug events and other adverse outcomes, including increased healthcare costs. Based on a secondary data analysis from the Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers (IDEM) randomized trial, this study found that increases in potentially inappropriate prescribing increased residents’ risk of going to the emergency room and increased total medication spending.
Magerøy MR, Braut GS, Macrae C, et al. BMC Health Serv Res. 2023;23:880.
Ensuring staff have a safe work environment and patients receive safe care are separate but complementary goals. This study describes how elected politicians and healthcare leaders balance workplace safety regulations and patient quality and safety goals in long-term care facilities. Tensions between the groups were identified (e.g., where leaders see flexibility, elected leaders see vagueness). Study themes include creating and improving channels for communication, and clear delineation of roles and responsibilities.
Mikkelsen TH, Søndergaard J, Kjaer NK, et al. BMC Geriatr. 2023;23:477.
Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.
Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.
Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.
Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.
Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.
Richman IB, Long JB, Soulos PR, et al. Ann Intern Med. 2023;176:1172-1180.
Overdiagnosis can result in overtreatment, physical harm, and emotional distress. Using SEER-Medicare data, researchers examined breast cancer overdiagnosis by comparing cancer incidence among women who discontinued mammography screening after age 70 compared to women who continued to receive screening mammograms. Findings suggest that breast cancer may be potentially overdiagnosed among 31% of women aged 70 to 74 years, 47% of women aged 75 to 84 years, and 54% of women aged 85 and older who continue to receive screening mammograms.
Erel M, Marcus E-L, DeKeyser Ganz F. Front Med (Lausanne). 2023;10:1145142.
Cognitive biases can influence treatment approach at the end of life. The goal of this study was to determine whether treatment approaches (e.g., palliative care to aggressive treatment) were associated with clinician cognitive biases in acute care settings for patients with advanced dementia and comorbidities. Representativeness, availability, and anchoring biases were associated with treatment approach in this hypothetical patient case; moral characteristics of the clinician were not associated with treatment approach.
Inadvertent overprescribing and polypharmacy in the 65-year old or older patient population is a contributor to patient harm. The Beers criteria serve as standard guidance for clinicians to prevent the potential for Inappropriate medication prescribing. This guideline updates existing recommendations and simplified the listing by removing rarely used medications in the geriatric population.
Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6:133.
Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.
Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.
Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.
Walsh DJ, Sahm LJ, O'Driscoll M, et al. J Geriatr Oncol. 2023;14:101540.
Older adults with cancer are typically prescribed multiple medications (i.e., polypharmacy) and are therefore at risk of adverse drug events (ADE). In this study, the medical records of older adults (those at least 70 years old) receiving cancer care who had an unplanned hospital admission were reviewed to determine if it was potentially related to an ADE. Of the hospitalized patients, more than half were potentially due to ADE at three and six months after the initial oncology visit. Including a clinical pharmacist may help reduce ADEs and hospitalizations.
Schattner A. Eur J Intern Med. 2023;115:29-33.
Older patients are particularly vulnerable to harm during hospitalization. This article summarizes potential patient harm that can occur during hospitalization for older adults, including unnecessary testing or procedures, nosocomial infections, medical errors, falls, functional or cognitive decline, and post-discharge adverse events.
Mohamed MR, Mohile SG, Juba KM, et al. Cancer. 2023;129:1096-1104.
Polypharmacy in older adults increases the risk of potentially inappropriate medications (PIM) and potential drug-drug interactions (PDI). This secondary analysis of a national study of older adults with advanced cancer sought to identify associations between polypharmacy (eight or more medications), PIMs, and PDIs with adverse cancer treatment outcomes. Polypharmacy and PDIs were associated with increased risk of adverse treatment outcomes, but PIMs were not.
Dadich A, Rodrigues J, De Bellis A, et al. Dementia (London). 2023;22:1057-1076.
Safety II involves studying what goes right in patient care instead of what went wrong. Using a video reflexive ethnography method and a Safety II approach, researchers analyzed the ways in which staff provided safe care in a specialized dementia ward. Identified themes included negotiating risk and balancing personhood vs. protocols.
Riester MR, Goyal P, Steinman MA, et al. J Gen Intern Med. 2023;38:1563-1566.
Potentially inappropriate medication (PIM) prescribing in older adults is common and can lead to medication-related harm. This retrospective study of Medicare beneficiaries estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin.
Xue Qin QN, Ming LC, Abd Wahab MS, et al. Res Social Adm Pharm. 2023;19:873-881.
Medication-related problems (including adverse drug events, medication errors, and potentially inappropriate prescribing) among patients with dementia or cognitive impairment can contribute to functional decline and poor outcomes. This systematic review of 15 studies found that the prevalence of medication-related problems among patients with dementia or cognitive impairments varied widely, from 9.1% to 83.6%.
Sanghavi P, Chen Z. JAMA Netw Open. 2023;6:e2314822.
Underreporting patient safety events can hinder opportunities for improvement. Building on previous research, this study examined the association between nursing home characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury and pressure ulcers). Findings suggest underreporting of both measures, and researchers identified an association between underreporting and the racial and ethnic composition of the nursing home facility. 
Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

Shahrestanaki SK, Rafii F, Najafi Ghezeljeh T, et al. BMC Health Serv Res. 2023;23:467.
Home care settings have unique patient safety challenges. This qualitative study including home care clinicians, inspectors, and family caregivers in Iran highlights that the healthcare team plays an important role in creating and promoting safe home care, including the use of individual risk assessments and mitigation of risk factors.