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.
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of family-centered rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Nickel WK, Weinberger SE, Guze PA, et al. Ann Intern Med. 2018;169:796-799.
Patient and family engagement can enhance both individual safety and organizational improvement efforts. This position paper advocates for patients and families to be active partners in all aspects of their care, treated with respect and dignity, engaged in improving health care systems, and directly involved in education of health care professionals. The piece also provides strategies to employ these recommendations in the daily practice.
Mann S, Hollier LM, McKay K, et al. New Engl J Med. 2018;379:1689-1691.
Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
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