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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 249 Results

Leonard A. KFF Health News. September 12, 2023.

The use of artificial intelligence (AI) holds potential for health care improvement that is beginning to be documented. This article discusses ChatGPT in the context of wide availability of internet search tools as a mechanism for patients to find answers to clinical questions. It summarizes clinicians’ concerns about the tools and strategies to being used to ensure the accuracy and safety of these searches.
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.
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.
Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.
Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Healthcare (Basel). 2023;11:2030.
Adverse events in palliative care can include inappropriate pain management, preventable hospital (re)admissions, falls, and pressure injuries. This paper outlines ways palliative care is not always received timely, the uniqueness of patient safety within palliative care, and how to raise awareness of both of these issues for healthcare providers, educators, and patients and families.
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.
Mirarchi FL, Pope TM. J Patient Saf. 2023;19:289-292.
Providing treatment that is discordant with patients’ preferences for end-of-life care can lead to unnecessary or unwanted treatment. This article summarizes the incidence of treatment discordant with their Portable Orders for Life Sustaining Treatment (POLST) and advanced directives (ADs) and tools for use by clinicians and patients and family members to promote concordant care. A previous PSNet WebM&M Spotlight Case discusses the importance of advanced care planning and the consequences of inadequate communication and planning for end-of-life care.
Lekman J, Lindén E, Ekstedt M. Scand J Caring Sci. 2023;Epub May 24.
Risk reduction in home health faces unique challenges. In this study of registered nurses providing home health, challenges included finding a balance between the patient's autonomy and ensuring a safe environment, building relationships with the patient and family, and gaps between resources and requirements.
Ekstedt M, Nordheim ES, Hellström A, et al. BMC Health Serv Res. 2023;23:581.
Remote patient monitoring (RPM) allows patients to remain in their homes while still receiving disease management. This study involved patients with chronic conditions who were receiving RPM and clinicians (nurses and physicians) who were providing RPM. Clinicians described the importance of knowing patients' level of health literacy and ensuring they understand when someone is reviewing their remote data (e.g., not on weekends). Patients reported feeling more confident, knowing someone was checking on them weekly. Overall, both groups had positive perceptions of patient safety.

Department of Health and Social Care. London, England: Crown Copyright; 2023

 

Following an investigation into the death of 11-month-old Elizabeth Dixon in the UK’s National Health System (NHS), a report with 12 recommendations for system improvement was released. This report sets out the government’s response to each recommendation, including the agency responsible for each recommendation, where applicable.
Lalani M, Wytrykowski S, Hogan H. BMJ Open. 2023;13:e067441.
Care integration —the linking of care across primary, secondary, social, community, and mental health—can improve care for patients with chronic conditions. In this review, 24 studies of integrated care were included. Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home or across settings (e.g., hospital and primary care). The authors recommend future research focus on safety targets beyond falls and medication safety and report on outcomes.
Longo BA, Schmaltz SP, Barrett SC, et al. Jt Comm J Qual Patient Saf. 2023;49:313-319.
Delivering health care in the home presents unique patient safety challenges. In this study, researchers identified significant associations between Joint Commission accreditation and measures of patient experience and patient safety with home health.
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.
Detollenaere J, Van Ingelghem I, Van den Heede K, et al. Eur J Pediatr. 2023;182:2735-2757.
The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.
Mortsiefer A, Löscher S, Pashutina Y, et al. JAMA Netw Open. 2023;6:e234723.
Polypharmacy among older adults can cause adverse health outcomes as well as adversely impact social outcomes, medication management, and healthcare utilization. The COFRAIL cluster randomized trial explored whether family conferences can promote deprescribing and reduce adverse outcomes related to polypharmacy in community-dwelling frail older adults. After 12 months of follow-up, the researchers did not find any significant difference in hospitalizations among patients randomized to family conferences or usual care. The number of potentially inappropriate prescriptions decreased among patients randomized to family conferences at 6-month follow-up, but this reduction was not sustained at the 12-month follow-up.
Larimer C, Sumner V, Wander D. Nutr Clin Pract. 2023;Epub Apr 19.
Medical lines, such as intravenous (IV), oxygen, or feeding tubes, provide lifesaving support but may also pose safety threats. Following a 2022 Food and Drug Administration safety communication regarding risk of strangulation by feeding tubes, researchers sought to determine if pediatric healthcare providers and caregivers were aware of the risk of medical line entanglement, and what, if any, type of education was provided to reduce the risk. Most providers were aware of the risk of entanglement, and 90% of caregivers reported their child had become entangled. However, less than 10% of caregivers received training to prevent such entanglements. Numerous comments from caregivers are provided, describing instances of entanglements and strategies they’ve used to prevent it.
Gorman LS, Littlewood DL, Quinlivan L, et al. BJPsych Open. 2023;9:e54.
Families can offer a unique perspective to improve patient care. This study describes ways families keep patients safe from suicide during crisis resolution home treatment in the UK. Families increased safety by hiding medications or distracting patients who were in crisis. Challenges to involving families are detailed, as well as ways organizations can overcome those challenges.

Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.

Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.

Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.