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 172 Results

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Staying safe while getting well.

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Salamon M. Harvard Women's Health Watch. August 1, 2023

Patients can help minimize the potential for adverse events while in the hospital. Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect against mistakes causing harm.

Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID-19.

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Albutt AK, Ramsey L, Fylan B, et al. Health Expect. 2023;26:1467-1477.

Patients' healthcare-seeking behaviors changed during the COVID-19 pandemic, particularly during the first wave. This longitudinal study sought patient perspectives about their experiences accessing healthcare, activities they undertook to keep themselves and others safe, and their understanding of healthcare system resilience and resources. Three themes emerged: a "new safety normal," existing vulnerabilities and heightened safety, and "are we all in this together?" The study highlighted that preexisting gaps in care experienced by those with chronic conditions or other vulnerabilities widened during the pandemic and deserve further research.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

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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.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Concerns regarding tablet splitting: a systematic review.

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Saran AK, Holden NA, Garrison SR. BJGP Open. 2022;6:BJGPO.2022.0001.

Tablet-splitting may introduce patient safety risks, such as unpredictable dosing. This systematic review and qualitative synthesis did not identify substantive evidence to support tablet-splitting concerns, with the exception of sustained-release tablets and use by older adults who may struggle to split tablets due to physical limitations.

Patients' experience of patient safety information and participation in care during a hospital stay.

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Tubic B, Finizia C, Zainal Kamil A, et al. Nurs Open. 2023;10:1684-1692.

Interventions to increase patient engagement in safety are receiving increasing attention. In this study, patients were given a safety leaflet containing information about how the patient can avoid adverse events during their hospital stay. Participants were overall satisfied about receiving information about their care but noted a lack of communication between healthcare personnel and patients regarding the safety leaflet.

The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging.

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Angel M, Bechard L, Pua YH, et al. Age Ageing. 2022;51:afac225.

People taking medications at home may have difficulty opening packaging which can result in improper, dangerous storage practices. This review includes 12 studies where participants were observed opening a variety of medication packages (e.g., blister packs, child-resistant containers). While all studies reported participant difficulty, no consistent contributory factors were identified, and the methodological quality of all studies was typically low. Additional research is required to encourage improvement in medication packaging.

How To Create a My Medicines List.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

This tool provides a printable template and step-by-step instructions for patients to create a visual reference for keeping track of medications.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic.

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Smith M, Vaughan Sarrazin M, Wang X, et al. J Am Geriatr Soc. 2022;70:1314-1324.

The COVID-19 pandemic disrupted healthcare delivery and contributed to delays in care. Based on a retrospective matched cohort of Medicare patients, this study explored the impact of the COVID-19 pandemic on patients who may be at risk for missed or delayed care. Researchers found that patients with four or more indicators for risk of missed or delayed care (e.g., chronic conditions, frailty, disability affecting use of telehealth) had higher mortality and lower rates of healthcare utilization, including primary care visits.

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

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Schnock KO, Roulier S, Butler J, et al. J Patient Saf. 2022;18:e407-e413.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

The source of purchased medications and its impact on medication mistakes and hospitalizations.

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Coates MC, Granche J, Sefcik JS, et al. Res Gerontol Nurs. 2022;15:69-75.

Older adults, especially those taking multiple medications, are at increased risk for medication self-administration (MSE) errors. Data from the National Health and Aging Trends Study (NHATS) was analyzed to ascertain if the source of the medication – picking up from local pharmacy, receiving the medication via mail-order pharmacy, or both – impacted MSE or hospitalization. Respondents receiving medications via both mail-order and pick up were more likely to report hospitalizations and medication mistakes.

When no news is bad news: improving diagnostic testing communication through patient engagement.

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Zomerlei T, Carraher A, Chao A, et al. J Patient Saf Risk Manage. 2021;26:221-224.

Failure to communicate abnormal test results to patients can lead to significant health complications and medical malpractice claims. This study aimed to increase patient engagement in asking their provider about previously obtained diagnostic test results. Reminders to follow up with their provider about test results were sent to the patient via the after-visit summary and patient portal. Patients receiving reminders were up to 20 times more likely to ask their providers about their test results, compared to patients who did not receive reminders.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Medicine self-administration errors in the older adult population: a systematic review.

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Aldila F, Walpola RL. Res Social Adm Pharm. 2021;17:1877-1886.

Older adults are at increased risk of medicine self-administration errors (MSEs) due to polypharmacy, cognitive decline, and decline in physical abilities. In this review, incorrect dosing was the most common MSE; the most common factor influencing the errors is complex medication regimens due to the need for multiple medications. Additional research is needed into how community pharmacists can assist older adults at risk of MSE.

Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic.

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Gualano MR, Lo Moro G, Voglino G, et al. Expert Opin Pharmacother. 2021;22:1051-1059.

Medication errors are a major source of preventable patient harm. Based primarily on data from national poison centers, this review summarizes the incidence self-administered medication errors in domestic settings and the role of healthcare professionals in ensuring that medication instructions are clear and understood by patients and caregivers.

The risks of the prescribing cascade.

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Brody JE. New York Times. 2020.

Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns.

Scoping review of patients' attitudes about their role and behaviours to ensure safe care at the direct care level.

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Duhn L, Godfrey C, Medves J. Health Expect. 2020;23:979-991.

This scoping review characterized the evidence base on patients’ attitudes and behaviors concerning their engagement in ensuring the safety of their care. The review found increasing interest in patient and family engagement in safety and identified several research gaps, such as a need to better understand patients’ attitudes across the continuum of care, the role of family members, and engagement in primary care safety practices.

Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days.

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Weir DL, Motulsky A, Abrahamowicz M, et al. Health Serv Res. 2020.

This study examined the effect of medication regimen changes at hospital discharge on adherence and adverse events among older adults. At 30-days post-discharge, nearly half of patients were nonadherent to at least one medication change, 26% visited the emergency department, 6% were readmitted to the hospital, and 0.5% died. Patients who were non-adherent to all medication changes had a 35% higher risk of adverse events within 30-days post-discharge compared to those were adherent to all changes.

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