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.
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
Stauffer BD, Fullerton C, Fleming N, et al. Arch Intern Med. 2011;171:1238-43.
This study found that adoption of a nurse-led transitional care program produced a 48% reduction in readmission rates for elderly patients with heart failure. Interestingly, the outcomes achieved generated only marginal cost savings, suggesting the need for payment reform to better align incentives.
This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child.