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Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
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.
Scobie A. Int J Qual Health Care. 2011;23:182-6.
Improving patient safety in the ambulatory setting requires the development of new care models, greater utilization of information technology, and a focus on patient factors such as health literacy. Current health policy reform often debates the virtues of international care delivery models as a driver for change. Building on past Commonwealth Fund reports, this study surveyed patients with self-reported chronic disease in eight countries to identify risk factors associated with self-reported errors. Investigators found that errors were associated with a number of factors, including a patient’s age, education level, and prescription drug use. The three risk factors with the greatest relationship to errors were experiencing a care coordination problem, having seen four or more doctors within the past 2 years, and having used the emergency department in the last 2 years. The authors advocate for improved sharing of clinical information (e.g., electronic health records) and specific policy and practices designed to improve care coordination.
Cohen MR.
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. 
Cohen MR.
This monthly selection of medication error reports includes an error averted because the pharmacist checked the patient's prior prescription data and a dosing error due to consumer confusion about dose measurement.