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Hada A, Coyer F. Nurs Health Sci. 2021;23:337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
Manias E, Bucknall T, Hughes C, et al. BMC Geriatr. 2019;19:95.
Transitions of care represent a vulnerable time for patients. Older adults in particular may experience a variety of challenges related to such transitions, including managing changes to their medications. This systematic review suggests that there is significant opportunity for health care providers to improve family engagement in managing medications of elderly patients during care transitions.
Almanasreh E, Moles R, Chen TF. Br J Clin Pharmacol. 2016;82:645-658.
Accurate medication reconciliation has been shown to improve patient safety across multiple care settings, yet barriers to implementation persist. This systematic review found significant variation across studies in how medication discrepancies were identified and classified. Researchers suggest that the use of a standardized taxonomy would better facilitate efforts to mitigate medication discrepancies and improve patient safety.
Mekonnen AB, McLachlan AJ, Brien J-AE. J Clin Pharm Ther. 2016;41:128-144.
Medication reconciliation was initially established as a National Patient Safety Goal in 2005. This systematic review included 19 studies that supported the positive impact of pharmacy-led medication reconciliation on decreasing discrepancies during hospital admission and discharge.
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.
Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-40.
Poor care coordination has been shown to be a risk factor for preventable errors in the ambulatory setting, and patients consistently voice concern about care coordination problems. This survey, which builds on prior Commonwealth Fund reports, found that care coordination was a major determinant of patient-reported medication errors in all seven countries studied. The study reinforces the role of health systems in ambulatory patient safety, and the need for improved communication between providers and better integration of health systems to reduce preventable errors for outpatients.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.