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Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6:e425.
Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).
Spencer RA, Singh Punia H. Patient Educ Couns. 2021;104:1681-1703.
Communication failures during transitions of care can threaten safe patient care. Although this systematic review identified several tools to support communication between inpatient providers and patients during transitions from hospital to home, the authors did not identify any existing tools to support the post-discharge period in primary care.
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Kurteva S, Habib B, Moraga T, et al. Value Health. 2021;24:147-157.
Harms related to prescription opioid use are an ongoing patient safety challenge. Based on data from one hospital between 2014 and 2016, this cohort study found that nearly 50% of hospitalized patients were discharged with an opioid prescription, and 80% of those prescriptions were among patients discharged from a surgical unit. Opioid-related medication errors were more common in handwritten discharge prescriptions compared to electronic prescriptions; electronic prescriptions were associated with a 69% lower risk of opioid-related medication errors.
Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.
van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47:234-241.
Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17:e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from  hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30:755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.  

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers.

Under a program known as the Care Transitions Intervention ®, a Transitions Coach ® encourages patients who are transferring from either a hospital or a short-term skilled nursing facility stay to home to assert a more active role in their self-care. The program has consistently reduced 30-day hospital readmissions and costs as well as 180-day hospital readmissions, even in heavily penetrated Medicare Advantage markets in which the reduction of hospital use has been an explicit focus for many years.

Backman C, Cho-Young D. Patient Prefer Adherence. 2019;13:617-626.
Hospital discharge is a complex process that requires patient and caregiver engagement in order to transpire safely. Interviews with members of a Canadian patient safety organization who had recently been discharged from the hospital revealed that they desired better communication as well as more attention to their social determinants of health. A PSNet perspective discussed interventions to improve safety during the transition from hospital to home.
Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.