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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 135 Results
Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;Epub Sep 1.
Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21:618.
Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.
Hada A, Coyer F. Nurs Health Sci. 2021;23:337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17:e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from  hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Res Social Adm Pharm. 2020;17:677-684.
This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.
Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Achilleos M, McEwen J, Hoesly M, et al. Am J Health Syst Pharm. 2020;77.
Pharmacists are critical to ensuring safe transitions between acute care and skilled nursing facilities (SNFs). This retrospective study evaluated the frequency of missed doses of high-risk medications after hospital-to-SNF transfers and found that 60% of first doses of high-risk medications were given after the scheduled administration time. After implementation of a medication order process including pharmacist-led medication reconciliation, the average delay in medication administration decreased significantly. 
Jarrett T, Cochran J, Baus A. J Nurs Care Qual. 2020;35:233-239.
The Medications at Transitions and Clinical Handoffs Toolkit (MATCH) provides strategies to implement and improve medication reconciliation in healthcare. This article describes the implementation of MATCH in a rural primary care clinic and the resulting improvements in medication reconciliation workflows.
Herledan C, Baudouin A, Larbre V, et al. Support Care Cancer. 2020;28:3557-3569.
This systematic review synthesizes the evidence from 14 studies on medication reconciliation in cancer patients. While the majority of studies did not include a contemporaneous comparison group, they did report that medication reconciliation led to medication error identification (most frequently drug omissions, additions or dosage errors) in up to 88-95% of patients.
DeAntonio JH, Leichtle SW, Hobgood S, et al. J Surg Res. 2019;246:482-489.
Trauma patients are particularly vulnerable to medication errors due to the severity of their injuries and the multiple handoffs and transitions often occurring during their hospital stay. This article reviewed existing medication reconciliation strategies and found that many have poor accuracy, can be costly and time-consuming, and may not be applicable to a trauma population.  The authors comment on the urgent need for research supporting safe and efficient medication reconciliation in trauma patients.
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
Pandya C, Clarke T, Scarsella E, et al. J Oncol Pract. 2019;15:e480-e489.
Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
McDonald EG, Wu PE, Rashidi B, et al. J Am Geriatr Soc. 2019;67:1843-1850.
This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.
Trivedi A, Sharma S, Ajitsaria R, et al. Arch Dis Child Educ Pract Ed. 2019;105:122-126.
Medication reconciliation to ensure accuracy of patient medication lists has been difficult to implement. This project report describes an initiative to enhance the timeliness of medication reconciliation for pediatric inpatients. Use of Plan-Do-Study-Act cycles helped inform the evolution of the work. The authors emphasize the importance of engaging the entire care team as well as patients and families to enable completion of the process.
Manias E, Bucknall T, Hughes C, et al. BMC Geriatr. 2019;19:95.
Transitions of care represent a vulnerable time for patients. Older adults in particular may experience a variety of challenges related to such transitions, including managing changes to their medications. This systematic review suggests that there is significant opportunity for health care providers to improve family engagement in managing medications of elderly patients during care transitions.
Cheong V-L, Tomlinson J, Khan S, Petty D. Prescriber. 2019;30:29-34.
Geriatric patients are particularly vulnerable to medication-related harm. This article summarizes types of incidents and contributing factors to adverse drug events in older patients after hospital discharge. The authors recommend strategies to reduce medication-related harm, including discharge communication improvements, primary care collaboration, and postdischarge patient education.