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.
Scott J, Heavey E, Waring J, et al. BMJ Open. 2016;6:e011222.
Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.
Roter DL, Wolff J, Wu A, et al. BMJ Qual Saf. 2017;26:508-512.
Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.
Tothy AS, Limper HM, Driscoll J, et al. Jt Comm J Qual Patient Saf. 2016;42:281-5.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Coleman EA, Ground KL, Maul A. Jt Comm J Qual Patient Saf. 2015;41:502-7.
Efforts to improve patient safety during care transitions have had mixed success, possibly due to failure to effectively engage family and caregivers in the transition process. This study reports on the development and validation of a novel survey instrument that measures family and caregivers' preparation and self-efficacy around supporting patients at the time of hospital discharge.
Litchfield IJ, Bentham LM, Lilford RJ, et al. Br J Med Pract. 2015;65:e133-e140.
This interview study revealed shortcomings in the process for notifying patients of test results, mirroring findings from prior studies. Patients expressed a desire for consistent and timely test result notification and noted deficiencies in current processes.
Stickney CA, Ziniel SI, Brett MS, et al. J Pediatr. 2014;165:1245-1251.e1.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Turner K, Frush K, Hueckel R, et al. J Nurs Care Qual. 2013;28:257-64.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.