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.
Hamiel U, Hecht I, Nemet A, et al. Postgrad Med J. 2018;94:254-258.
Abbreviations are both ubiquitous in clinical documentation and frequently misinterpreted. This cross-sectional Israeli study found that only 1.2% of physicians could understand 50% or more of the abbreviations in ophthalmologists' notes. Israeli physicians document in Hebrew, but ophthalmologists there favor English abbreviations. The authors suggest that use of abbreviations should be discouraged due to the potential for misinterpretations to affect patient care.
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. PLoS One. 2018;13:e0193510.
Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.
Frankenthal D, Israeli A, Caraco Y, et al. J Am Geriatr Soc. 2017;65:e33-e38.
Inappropriate medication prescribing to older patients increases the risk of adverse drug events. This retrospective study assessed the sustainability of orally communicated medication recommendations based on the STOPP (Screening Tool of Older Persons potentially inappropriate Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria as compared to written medication review over time. The prevalence of potentially inappropriate prescriptions remained lower in the group receiving the orally communicated recommendations at 24-month follow-up. The authors conclude that direct communication about medications between pharmacists and prescribing providers may be more effective than written medication review.
Zohar D, Werber YT, Marom R, et al. BMJ Qual Saf. 2017;26:653-662.
This randomized controlled trial randomized head nurses in inpatient settings to either receive individual feedback based on questionnaires from frontline nurses followed by goal-setting, versus a summary report of feedback at the end of the intervention. In the intervention group, patient care messages increased and blaming decreased, demonstrating that a brief and feasible intervention can enhance safety culture.
Alolayan A, Alkaiyat M, Ali Y, et al. BMJ Qual Improv Rep. 2017;6.
Complex care regimens and poor team communication can influence the safety of patients with cancer. This project report describes how an organization used a standardized communication tool to augment physician handovers of oncology patients. The authors utilized plan-do-study-act cycles to refine the process. They found that each adjustment addressed challenges to the use of the tool and over time physician compliance with the process increased.
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Am J Health Syst Pharm. 2015;72:1266-8.
Miscommunication during transitions of care can contribute to medication errors. This commentary describes an initiative to involve pharmacy students in care transitions services. Although the authors found that scheduling and training the students for the program was a challenge, 30-day readmission rates were lower for patients who received transitions of care services with pharmacy students versus those who did not.
Drach-Zahavy A, Hadid N. J Adv Nurs. 2015;71:1135-45.
This prospective study examined 200 hospital nurse handovers. Documentation was missing in nearly half of patients' files, and dosage discrepancies were identified in 23% of cases. Use of strategies that emphasized the input and interaction of the incoming team—such as face-to-face verbal updates with questions—were associated with fewer treatment errors.
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