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.
Alolayan A, Alkaiyat M, Ali Y, et al. BMJ Qual Improv Rep. 2017;6.
Complex care regimens and poor team communication can influence the safety of patients with cancer. This project report describes how an organization used a standardized communication tool to augment physician handovers of oncology patients. The authors utilized plan-do-study-act cycles to refine the process. They found that each adjustment addressed challenges to the use of the tool and over time physician compliance with the process increased.
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Am J Health Syst Pharm. 2015;72:1266-8.
Miscommunication during transitions of care can contribute to medication errors. This commentary describes an initiative to involve pharmacy students in care transitions services. Although the authors found that scheduling and training the students for the program was a challenge, 30-day readmission rates were lower for patients who received transitions of care services with pharmacy students versus those who did not.
Drach-Zahavy A, Hadid N. J Adv Nurs. 2015;71:1135-45.
This prospective study examined 200 hospital nurse handovers. Documentation was missing in nearly half of patients' files, and dosage discrepancies were identified in 23% of cases. Use of strategies that emphasized the input and interaction of the incoming team—such as face-to-face verbal updates with questions—were associated with fewer treatment errors.
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