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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 - 12 of 12 Results
Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4:e2119346.
Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.
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).
Patient Safety Innovation May 26, 2021

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

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.
Hannum SM, Abebe E, Xiao Y, et al. Appl Ergon. 2020;91:103299.
Discharge can be a vulnerable time for patients, particularly older adults taking multiple medications. Through interviews with clinicians from 10 professional roles, researchers identified three key strategies to promote safe medication management at hospital discharge: (1) streamlining medication reconciliation across care settings, (2) building patient capacity and engagement, and (3) redesigning the transitional process. Aligning clinician and patient care transition goals using these three strategies may better prepare patients to safely self-manage their medications at home.   
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.
Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;147:e20200031.
Breakdowns in communication between clinicians and patients and their caregivers are common and can lead to adverse events. This article describes the development of the SAFER Care framework for written and verbal discharge counseling in pediatric units. The SAFER mnemonic reminds clinicians delivering discharge counseling to discuss safe return to school/daycare, activity restrictions, follow-up plans expected symptoms after discharge, when to return and seek care for symptoms, and who to contact with questions. Results from caregiver surveys indicate that the SAFER Care framework improved their comprehension of discharge instructions.
WebM&M Case December 23, 2020

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

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.
Society of Hospital Medicine
This Web site provides resources associated with the Better Outcomes for Older adults through Safe Transitions project, called Project Boost. This national initiative designed tactics to improve the safety and quality of patient transitions from hospital to home. The program provided hospitals with implementation assistance to use tools in general and specifically for their environments, such as pediatrics.
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.