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.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications.
Thomas DB, Newman-Toker DE. Diagnosis (Berl). 2016;3:49-59.
This case study describes five cases of dizziness, each incorrectly diagnosed by a physician and subsequently correctly diagnosed by a physical therapist. The authors argue for involving allied health professionals in the diagnostic process, as recommended in the Improving Diagnosis report.
Jackson PD, Biggins MS, Cowan L, et al. Rehabil Nurs. 2016;41:135-48.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.
Weinberg DB, Gittell JH, Lusenhop W, et al. Health Serv Res. 2007;42:7-24.
The investigators surveyed patients regarding the coordination of their postdischarge care and identified problems with coordination across settings, within settings, and between patients and providers.
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