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
Additional Filters
Displaying 1 - 20 of 585 Results
Weaver SH, de Cordova PB, Ravichandran A, et al. J Nurs Care Qual. 2022;Epub Dec 7.
Nurse work environment has been linked to perceived safety culture and job satisfaction. This cross-sectional survey of licensed practical nurses (LPNs) in New Jersey found lower job satisfaction and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working in other settings.

Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.
Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.
Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.
Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.
Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.
Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.
Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.
Sterling MR, Lau J, Rajan M, et al. J Am Geriatr Soc. 2022;Epub Dec 5.
Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).

Agency for Healthcare Research and Quality. January 24, 2023, 1:00 – 2:00 PM (eastern).

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session will introduce the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey will be shared.
Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.
Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.
Svedahl ER, Pape K, Austad B, et al. BMJ Qual Saf. 2022;Epub Dec 15.
Inappropriate referrals and unnecessary hospital admissions are ongoing patient safety problems. This cohort study set in Norway examined the impact of emergency physician referral thresholds from out-of-hours services on patient outcomes.  
Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Drug Saf. 2022;45:1501-1516.
Adverse events, such as medication errors, are a major cause of hospital admissions. This retrospective study of a subset of OPERAM intervention patients who were readmitted with a potentially preventable drug-related admission (DRA) examined whether use of STOPP/START criteria during in-hospital medication review can identify medication errors prior to a potentially preventable DRA. Researchers found that medication errors identified at readmission could not be addressed by prior in-hospital medication reviews because the medication error occurred after the in-hospital review or because recommended medication regimen changes were not provided or not implemented.
Wallerstedt SM, Svensson SA, Lönnbro J, et al. JAMA Netw Open. 2022;5:e2236757.
Criteria, such as the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, are tools used by clinicians to identify potentially inappropriate prescribing (PIM) and potential prescribing omissions (PPOs) among older adult patients. In this study, researchers evaluated three PIM/PPO criteria sets and found that all three performed poorly as diagnostic tools to identify inadequate drug treatment in older patients compared to counting the number of drugs on the patient’s medication list.
Thevelin S, Pétein C, Metry B, et al. BMJ Qual Saf. 2022;31:888-898.
Polypharmacy can place older adults at increased risk of adverse drug events. This mixed-methods study, embedded in the OPERAM trial, identified differences in perceived shared decision-making regarding medication changes between providers and older adult patients. Whereas clinicians reported high levels of shared decision-making, patients reported poor communication and paternalistic decision-making.
Farrell TW, Hung WW, Unroe KT, et al. J Am Geriatr Soc. 2022;70:3366-3377.
Research into the impact of racism on health outcomes has increased in recent years, but there has been less emphasis on ageism or the intersection of ageism and racism. This commentary highlights the ways racism (e.g., clinical algorithms), ageism (e.g., proposed measures to ration care) and the intersection of the two (increased morbidity and mortality of COVID-19 on older people of color) impacts health outcomes. Recommendations for current clinicians and health profession educators are provided.
Kim K-A, Lee J, Kim D, et al. BMC Health Serv Res. 2022;22:1376.
Safety culture has been shown to be associated with nursing home quality indicators such as discharge to community and injuries related to falls and catheters. Numerous surveys exist to measure safety culture. This review identified seven measurement tools, and the most frequently used tool was the Nursing Home Survey on Patient Safety Culture. The Hospital Survey on Patient Safety Culture, Safety Attitudes Questionnaire, and Modified Stanford Patient Safety Culture Survey Instrument were also used.
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.
Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.

Schneider E, Koretz BK, eds. Clin Geriatr Med. 2022;38(4):621-732.

Polypharmacy is a known contributor to medication complexity and error. This special issue examines the impact unnecessary medications have in a variety of care environments, such as nursing homes and emergency departments, and clinical areas, such as oncology and behavioral health.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333. 

The care of older adult patients can be complicated due to comorbidities, bias and polypharmacy. This publication reports on a session that examined diagnostic challenges unique to the older adult population. The existing evidence base and strategies for the future are reviewed.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Int J Clin Pharm. 2022;44:1434-1441.
Older adults taking multiple medications are at increased risk for adverse drug events following hospital discharge. In this study, patients were contacted two weeks after hospital discharge to evaluate adverse events, adverse drug events, and health-related quality of life (HRQoL). There was a weak but significant correlation between patient-reported adverse events and HRQoL, but not patient-reported adverse drug events.