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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 - 7 of 7 Results
Li SYW, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.
Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-7.
Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.
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.
Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-80.
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.
Schnipper JL, Kirwin JL, Cotugno MC, et al. Arch Intern Med. 2006;166:565-571.
This study found a lower rate of preventable adverse drug events (ADEs) for patients who received medication review, counseling, and telephone follow-up from a hospital pharmacist. Investigators randomized nearly 100 medical patients to receive the pharmacy intervention and found that only 1% of those patients experienced a preventable ADE (11% in the control group). The overall rate of ADEs was similar in both groups. Additional findings included observation of unexplained discrepancies between preadmission and discharge medication regimens in nearly half the patients. This finding supports national interests in medication reconciliation. A past study suggested similar benefits of pharmacy participation in daily rounds in an intensive care unit.
Schoen C, Osborn R, Huynh PT, et al. Health Aff (Millwood). 2005;24;Suppl1.
This Commonwealth Fund-sponsored survey provides an international perspective from patients from Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Overall, the findings collectively suggest that no single country stands alone as the best or worst in the identified health care issues. These issues included transitional care and care coordination, medication safety, chronic care management and patient-centered care, and timely access. The United States, for instance, seemed to suffer from fragmentation of care and inadequate insurance as well as limitations in access and efficiency. However, each country shared certain strengths and challenges. The findings suggest that fundamental changes to health care will be necessary, beyond current efforts targeting payment and delivery systems.
Spear SJ. Harv Bus Rev. 2005;83:78-91, 158.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.