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.
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51:520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.
Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;22:2196-2200.
Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.
Oliveira J. e Silva L, Vidor MV, Zarpellon de Araújo V, et al. Mayo Clin Proc. 2020;95:1842-1844.
This article discusses the threat that the “flexibilization” of science has played during the COVID-19 pandemic, defined as the loosening of methodological standards leading to low-quality studies, and resulting in unreliable data and anecdotal evidence.
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.
Fraczkowski D, Matson J, Lopez KD. J Am Med Inform Assoc. 2020;27:1149-1165.
The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design.
Freeling M, Rainbow JG, Chamberlain D. Int J Nurs Stud. 2020;109:103659.
This literature analysis assessed the evidence on the impact presenteeism in the nursing workforce and found that presenteeism is associated with risk to nurse well-being and patient safety, but that additional research exploring the relationship between presenteeism, job satisfaction, and quality of care is needed.
This pilot study evaluated the impact of transitional care pharmacist medication-related interventions in skilled nursing settings on 30-day hospital readmissions. The intervention group received transitional services involving a pharmacist (such as medication reconciliation, coordination with the skill nursing case manager and physician, and patient/caregiver education) and the control group received transitional services without pharmacist involvement. Over the follow-up period, median time to readmission was significantly longer in the intervention group but 30-day readmission rates were non-statistically significantly lower in the intervention compared to control group.
Balsom C, Pittman N, King R, et al. Int J Clin Pharm. 2020:Epub Jun 3.
Polypharmacy is one risk factor for medication errors in older adults. This study describes the implementation of a pharmacist-administered deprescribing program in a long-term care facility in Canada. Over a one-year period, residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. The intervention resulted in fewer medications taken by residents the intervention group after 6 months. Most deprescribing recommendations reflected a lack of ongoing indication or a dosage that was too high.
Singh H, Sittig DF. Ann Intern Med. 2020;172:S92-S100.
This article describes the Safety-related EHR Research (SAFER) Reporting Framework, which facilitates reporting patient safety-focused EHR interventions through a sociotechnical lens. It discusses the benefits of a sociotechnical approach to reporting and components to operationalizing the SAFER framework, including necessary hardware and software, clinical content, a human-computer interface, workflow and communication, rules and regulations, and measurement and monitoring. SAFER is not intended to replace current research reporting guidelines, but complement their use.
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.
Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.
Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.
Lampert A, Haefeli WE, Seidling HM. J Patient Saf. 2020;16.
Through focus groups with patients, family caregivers and nurses, this study explored experiences with medication administration and perceived needs for assistance. Patients and caregivers were generally unaware of errors and primarily attributed administration problems to dosage form (eg, lack of confidence in using syringes). Participants identified lack of training or education about proper administration as contributing to administration errors.
Dzau VJ, Kirch D, Nasca TJ. N Engl J Med. 2020;383:513-515.
This commentary discusses the ongoing impact of COVID-19 on the physical, emotional, and mental health on the healthcare workforce and outlines five high-priority actions at the organizational- and national level to protect the health and wellbeing of the healthcare workforce during and after the pandemic.
Ogletree AM, Mangrum R, Harris Y, et al. J Am Med Dir Assoc. 2020;21:604-614.e6.
To support the development of a uniform definition of omissions of care in nursing home settings, the authors conducted a thematic analysis of 34 articles describing existing definitions and found broad agreement that delays or failure of care constitutes an omission of care, but differing views on whether to include adverse events in the definition of omissions of care. The authors reviewed an additional 327 articles reporting adverse events attributable to omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls, and infections.
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:101.
Organizational cultures that encourage psychological safety has been shown to increase safe healthcare practices. This systematic review evaluated fourteen studies targeting psychological safety, speaking up and voice behavior within healthcare settings; studies primarily used educational interventions including simulation (5 studies), video presentations (2 studies), case studies (3 studies) or workshops (1 study). While some interventions showed improvement in psychological safety, this was not consistently demonstrated across studies. The authors note that the ability to demonstrate improvements were limited by lack of objective outcome measures and the inability of educational interventions alone to result in behavior change.
Song Y, Hoben M, Norton PG, et al. JAMA Netw Open. 2020;3.
The authors surveyed over 4,000 care aids from 93 urban nursing homes in Western Canada to assess the association of work environment with missed and rushed essential care tasks. During their most recent shift, over half of care aids (57.4%) reported missing at least one essential care task and two-thirds (65.4%) reported rushing at least one essential care task. Work environments with better work culture and more effective leadership were associated with fewer missed or rushed care tasks.
Cheraghi-Sohi S, Panagioti M, Daker-White G, et al. Int J Equity Health. 2020;19:26.
To better understand patient safety issues of marginalized groups, this scoping review assessed 67 articles primarily focusing on four patient groups: ethnic minorities, frail elderly, care home residents and those with low socioeconomic status. A variety of patient safety issues were identified, and half of the included studies looked at either medication safety, adverse outcomes, and near misses. This review highlights the need for additional research to understand the intersection between marginalization and the multi-dimensional nature of patient safety issues.
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