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.
Evidence is building to delineate the effect of systemic bias on care safety. This article recognizes the flaws of pulse oximeters on patients with darker skin, gaps in the literature base, and the work of regulatory bodies to consider redesign and regulation of the device to address bias.
Hsiao AL, Shiffman RN. Jt Comm J Qual Patient Saf. 2009;35:467-74.
Discontinuity between providers is a well-documented source of errors, as prior research has documented safety problems arising from handoffs and signouts in the hospital and at the time of hospital discharge. The need for accurate information transfer between providers is no less important for patients seen in the emergency department (ED), but this study found that most pediatricians were unaware that their asthma patients had required an ED visit. This occurred despite the existence of a structured system for communication between the ED and primary care physicians. Many patients also failed to follow up in clinic as instructed, perhaps corroborating prior research showing that many ED patients do not fully comprehend discharge instructions. This study adds another facet to the problem of patient safety in chronic disease management.
Porter SC, Kohane IS, Goldmann DA. J Am Med Inform Assoc. 2005;12:299-305.
This study examined the utility of a multimedia kiosk to capture parents’ knowledge of their children’s asthma medication history. Investigators compared the parental information with that documented by emergency department providers. Results suggested greatest accuracy in medication name followed by route of delivery, form of medication, and dose. The authors conclude that patient-derived data can be effective in improving current deficits in medication documentation during emergency department visits.
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