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 - 20 of 33 Results

Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure.

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Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.

Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.

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Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;183:658-668.

Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

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Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

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Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.

Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

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Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Drug Saf. 2022;45:1501-1516.

Adverse events, such as medication errors, are a major cause of hospital admissions. This retrospective study of a subset of OPERAM intervention patients who were readmitted with a potentially preventable drug-related admission (DRA) examined whether use of STOPP/START criteria during in-hospital medication review can identify medication errors prior to a potentially preventable DRA. Researchers found that medication errors identified at readmission could not be addressed by prior in-hospital medication reviews because the medication error occurred after the in-hospital review or because recommended medication regimen changes were not provided or not implemented.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.

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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.

Dedicated teams to optimize quality and safety of surgery: a systematic review.

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Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Int J Qual Health Care. 2022;34:mzac078.

Effective teamwork training for surgical teams can improve post-operative mortality rates. This review aimed to evaluate the effect of a dedicated surgical team (e.g., a team who received technical and/or communication teamwork training) on clinical and performance outcomes. Implementation of dedicated surgical teams resulted in improved mortality rates, but no difference in readmission rates or length of stay.

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.

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Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.

Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.

Society for Maternal-Fetal Medicine Special Statement: a critique of postpartum readmission rate as a quality metric.

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Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:b2-b9.

Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.

Association of measured quality with financial health among U.S. hospitals.

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Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.

While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.

Post-Acute Transitional Services: Safety in Home-Based Care Programs

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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.

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

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El Abd A, Schwab C, Clementz A, et al. J Patient Saf. 2022;18:230-236.

Older adults are at high risk for 30-day unplanned hospital readmission. This study identified patient-level risk factors among patients 75 years or older who were initially hospitalized for fall-related injuries. Risk factors included being a male, abnormal concentration of C-reactive protein, and anemia. Discharge programs targeting these patients could reduce 30-day unplanned readmissions.

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

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Muchiri S, Azadeh-Fard N, Pakdil F. J Patient Saf. 2022;18:237-244.

The Hospital Readmissions Reduction Program (HRRP), implemented by the Centers for Medicare & Medicaid Services (CMS), imposes a financial penalty on hospitals with higher than average readmission rates for certain conditions. Six years of readmission rates for four conditions included in the HRRP (acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia) and two conditions not included (septicemia and mood disorders) were analyzed to assess the impact of the HRRP. The researchers conclude the HRRP reduced readmission rates for the four targeted conditions, but reductions were not consistent across all categories of patients.

The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission

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Patient Safety Innovation April 7, 2022

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.¹ Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.² Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.²

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.

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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.

The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England.

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Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18:7581.

Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.

Effects of pharmacist-conducted medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary disease.

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Singh D, Fahim G, Ghin HL, et al. J Pharm Pract. 2021;34:354-359.

Pharmacist-led medication reconciliation has been found to reduce medication discrepancies for some patients. This retrospective study examined the impact of pharmacist-conducted medication reconciliation among patients with chronic obstructive pulmonary disease (COPD). While pharmacist-conducted medication reconciliation identified medication dosing and frequency errors, it did not reduce 30-day readmission rates for patients with COPD.

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

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Patient Safety Innovation May 26, 2021

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

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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.

The association of nursing home characteristics and quality with adverse events after a hospitalization.

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Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;22:2196-2200.

Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.

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