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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 - 20 of 66 Results
Dietz I, Borasio GD, Molnar C, et al. J Palliat Med. 2013;16:74-81.
… Journal of palliative medicine … Patients receiving palliative care can be medically complex and often require … far, few studies have examined patient safety risks in palliative care patients. This survey of palliative medicine …
WebM&M Case November 1, 2017
… … Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communication are common in palliative care. Describe key principles regarding the use of opioids in palliative care. Recognize the principle of double effect and …
Heneka N, Bhattarai P, Shaw T, et al. Palliat Med. 2019;33:430-444.
This focus group study of Australian palliative care providers examined risk factors for opioid errors among palliative patients. They identified clinician inexperience, the drug preparation environment, and poor communication as contributory factors for medication errors. The authors conclude that multiple interventions will be needed to enhance opioid safety in palliative care.
Yardley I, Yardley S, Williams H, et al. Palliat Med. 2018;32:1353-1362.
The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care.
Gallagher R, Passmore MJ, Baldwin C. Med Hypotheses. 2020;142:109727.
The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.
Williams H, Donaldson SL, Noble S, et al. Palliat Med. 2019;33:346-356.
Palliative medicine … Patients receiving palliative care are often medically complex and may be at … reports regarding patients who received inadequate palliative care during nights and weekends from primary care …
Pedrosa Carrasco AJ, Bezmenov A, Sibelius U, et al. Am J Hosp Palliat Care. 2022:104990912211400.
Patients with medical complexities who are receiving palliative care may be at increased risk for patient safety events. This cross-sectional survey found that patient safety concerns were common among patients receiving specialist community palliative care in Germany. Patients reported that physical disability, physical and psychological symptoms, and side effects or complications from medication therapy were the most common causes of impaired safety, as well as the COVID-19 pandemic.
Pestian T, Thienprayoon R, Grossoehme D, et al. Pediatr Qual Saf. 2020;5:e328.
The authors used qualitative data to evaluate parental perspectives of quality in pediatric home-based hospice and palliative care (HBHPC) programs, and how parents define “safe care” in the home. Thematic analysis identified eight domains of safety prioritized by patients, including an emphasis on the safety of the physical environment, medication safety, maintaining comfort and preventing harm, and trust in the HBHPC caregivers.
WebM&M Case September 1, 2004
… five times per year, and refers patients to hospice-based palliative care five times per year.( 1 ) Among these … of physicians caring for patients already enrolled in palliative care. These studies reveal that, on average, … patients at the time of patient referral to hospice-based palliative care. These estimates were then compared with …
WebM&M Case March 31, 2022
… trainees Articulate the importance of early referral to palliative care Recognize implicit bias when caring for … but was unsure why he was not receiving treatment. The palliative care service was consulted to clarify goals of … the current admission. During this prior admission, the Palliative Care team called the patient’s daughter to obtain …
WebM&M Case July 8, 2022

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.