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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 - 9 of 9 Results
Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.
Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.
Patient Safety Primer April 27, 2022

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59:901-906.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Uitvlugt EB, Janssen MJA, Siegert CEH, et al. Front Pharmacol. 2021;12:567424.
Identifying and reducing potentially preventable readmissions is a patient safety priority. This study found that 16% of readmissions at one teaching hospital in the Netherlands were medication-related; of those, 40% were considered potentially preventable. Preventable readmissions were attributed to prescribing errors, non-adherence, and handoff or transition errors.
Herges JR, Garrison GM, Mara KC, et al. J Am Pharm Assoc (2003). 2020;61:68-73.
The goal of medication reconciliation is to prevent adverse events by identifying unintended medication discrepancies during transitions of care. This retrospective cohort evaluated the impact of attending a pharmacist-clinician collaborative (PCC) visit after hospital discharge with their medication containers on risk of 30-day readmission. Among adult patients on at least 10 total medications, findings indicate no significant difference in 30-day hospital readmission risk between patients presenting to a PCC visit with their medication containers compared with patients who did not. However, when patients did present to their PCC visit with medication containers, pharmacists identified more medication discrepancies and resolved more medication-related issues.
WebM&M Case August 26, 2020

A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital.

Daliri S, Boujarfi S, el Mokaddam A, et al. BMJ Qual Saf. 2021;30:146-156.
This systematic review examined the effects of medication-related interventions on readmissions, medication errors, adverse drug events, medication adherence, and mortality. Meta-analyses indicate that medication-related interventions reduce 30-day readmissions and the positive effect increased with higher intervention intensities (e.g., additional intervention components). Additional research is required to determine the effects on adherence, mortality, and medication errors and adverse drug events.
Amin PB, Bradford CD, Rizos AL, et al. J Pharm Pract. 2020;33:306-313.
This pilot study evaluated the impact of transitional care pharmacist medication-related interventions in skilled nursing settings on 30-day hospital readmissions. The intervention group received transitional services involving a pharmacist (such as medication reconciliation, coordination with the skill nursing case manager and physician, and patient/caregiver education) and the control group received transitional services without pharmacist involvement. Over the follow-up period, median time to readmission was significantly longer in the intervention group but 30-day readmission rates were non-statistically significantly lower in the intervention compared to control group.
Weir DL, Motulsky A, Abrahamowicz M, et al. Health Serv Res. 2020.
This study examined the effect of medication regimen changes at hospital discharge on adherence and adverse events among older adults. At 30-days post-discharge, nearly half of patients were nonadherent to at least one medication change, 26% visited the emergency department, 6% were readmitted to the hospital, and 0.5% died. Patients who were non-adherent to all medication changes had a 35% higher risk of adverse events within 30-days post-discharge compared to those were adherent to all changes.