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 - 13 of 13 Results

Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis.

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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.

Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events.

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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).

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

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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.

Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge and its associated adverse drug outcomes.

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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.

The association of nursing home characteristics and quality with adverse events after a hospitalization.

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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.

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

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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.

Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare.

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Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.

SAFER Care: improving caregiver comprehension of discharge instructions.

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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.

Prehospital naloxone and emergency department adverse events: a dose-dependent relationship.

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Maloney LM, Alptunaer T, Coleman G, et al. J Emerg Med. 2020;59:872-883.

Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).

What is an ethically informed approach to managing patient safety risk during discharge planning?

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West JC. AMA J Ethics. 2020;22:e919-e923.

Patient safety is a concern throughout the entire process of care from admission to discharge. This article highlights the role of risk managers to assure that patients return to a home environment that can enable their safe recovery whether the discharge is advised or not.

Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study.

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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.

Advancing Successful Care Transitions to Improve Outcomes.

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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.

Using medication reconciliation to prevent errors.

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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.

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