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.
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.
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.
Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.
Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.
Despite the support for maintaining medication lists in electronic health records, these lists can contain and perpetuate errors. This commentary suggests that a set of standards are needed to ensure accuracy of electronic medication lists and reduce unnecessary or duplicate prescriptions in discharge instructions.
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.
Griesbach S, Lustig A, Malsin L, et al. J Manag Care Spec Pharm. 2016;21:330-336.
This study of a quality improvement initiative found that automated screening of prescribing data uncovered many potential adverse drug events. Prescribers were notified about these safety concerns, and almost 80% of these potential adverse drug events were resolved through prescription changes. The extent of patient harm which occurred or was averted was not reported. This work suggests that real-time data from electronic prescribing could be harnessed to improve patient safety, as others have suggested.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
This study adopted SBAR as part of a handoff curriculum, and found that it addressed commonly encountered communication issues. Implementation of the standardized communication tool was linked to a decrease in order entry errors.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-95.
This study found that 62% of patients transferred between units during a hospitalization had at least one unintentional medication discrepancy. The most common discrepancy was medication omission, independent of which system was used (e.g., paper versus computerized).
Boockvar KS, Livote EE, Goldstein N, et al. Qual Saf Health Care. 2010;19:e16.
Addressing handoffs in patient care is a continued challenge, particularly around medication safety. Medication reconciliation was seen as a preventive strategy to handle such concerns, though the lack of proven strategies led The Joint Commission to soften its previous National Patient Safety Goal. A commonly held belief is that electronic health records (EHRs) provide solutions to communicating health information. This study compared medication reconciliation events for patient handoffs within a computerized VA system to a paper-based system outside the VA. Interestingly, there was no significant difference between medication discrepancies and adverse drug events (ADEs) in the highly computerized system. The authors suggest that their findings support a need for specialized tools to facilitate medication review at times of transfer. A past AHRQ WebM&M commentary discussed medication reconciliation after an avoidable error.
Lesselroth B, Adams S, Felder R, et al. Jt Comm J Qual Patient Saf. 2009;35:264-70.
This study used an innovative approach to involving patients in safety efforts by using an interactive kiosk paired with the medication list from the electronic health record. When patients presented for a clinic visit, the kiosk presented their presumed medication list along with pill pictures, and patients had to indicate if they were taking the medication. This method successfully identified medication discrepancies and reduced the time spent by staff in reviewing medications. Ensuring medication reconciliation in ambulatory care has been particularly problematic for patients with low health literacy. This novel strategy may represent an effective, patient-centered approach to this problem.
Attempts to reduce medication discrepancies in hospitalized patients have been hampered by a lack of proven medication reconciliation strategies. In this cluster-randomized trial, a previously described electronic medication list that required input from nurses, physicians, and pharmacists was implemented at two academic hospitals. The tool resulted in a significant reduction in potential adverse drug events at discharge. However, potential drug errors still occurred at a rate of one per patient even after implementation. The intervention was more successful at preventing medication discrepancies among high-risk patients. This study is one of the first randomized trials of a medication reconciliation intervention, and points the way toward identifying medication reconciliation tools that are widely applicable.
El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-8.
Less than 20% of ambulatory practices in the United States utilize electronic health records (EHRs). Uptake has been limited by cost issues and concern about the impact of EHRs on clinician workflow. This survey evaluated clinicians' perceptions of a newly implemented electronic medical record in three primary care clinics. Although initially clinicians felt that the EHR resulted in longer patient visits and increased the time spent documenting, by 1 year after implementation, clinicians felt that the EHR improved their ability to follow up on test results and communicate with other providers, and contributed to higher quality care overall. Importantly, these perceived advantages emerged only after 1 full year of using the new system.
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