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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 31 Results

Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment.

Save to Library

Mirarchi FL, Pope TM. J Patient Saf. 2023;19:289-292.

Providing treatment that is discordant with patients’ preferences for end-of-life care can lead to unnecessary or unwanted treatment. This article summarizes the incidence of treatment discordant with their Portable Orders for Life Sustaining Treatment (POLST) and advanced directives (ADs) and tools for use by clinicians and patients and family members to promote concordant care. A previous PSNet WebM&M Spotlight Case discusses the importance of advanced care planning and the consequences of inadequate communication and planning for end-of-life care.

Critical Echocardiogram Result Lost to Follow-up.

Save to Library

WebM&M Case June 14, 2023

A 63-year-old man presented from a skilled nursing facility (SNF) with shortness of breath and was treated for mild heart failure exacerbation. An echocardiogram was performed but results were pending on discharge, with anticipation that the patient’s primary care provider would follow up the results. Two weeks later, the patient was readmitted from the SNF and was found to have endocarditis and infected pacemaker wires.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

Save to Library

Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Preventable Transfer to the Hospital

Save to Library

WebM&M Case July 8, 2022

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

Nursing and Patient Safety

Save to Library

Patient Safety Primer April 21, 2021

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.

Discrepant advanced directives and code status orders: a preventable medical error.

Save to Library

Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.

Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors.

Implementing a warm handoff between hospital and skilled nursing facility clinicians.

Save to Library

Britton MC, Hodshon B, Chaudhry SI. J Patient Saf. 2019;15:198-204.

This implementation study describes a new workflow of a telephone call between discharging clinician at an acute care hospital and treating physician at a skilled nursing facility to improve handoffs. Researchers report increasing implementation of this "warm handoff," tempered by concerns about clinician workload and efficiency. The authors conclude that while warm handoffs show promise, the organizational and workflow context could better support this safety strategy.

Patient Safety 101

Save to Library

Patient Safety Primer September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Adverse events in long-term care residents transitioning from hospital back to nursing home.

Save to Library

Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.

Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

Save to Library

Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.

Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.

Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.

Save to Library

Lane SJ, Troyer JL, Dienemann JA, et al. Health Care Manag Rev. 2014;39:340-351.

According to this study, dose omissions were the most common medication errors occurring during transitions to nursing home care. However, the wide range of errors detected suggests that multifaceted interventions would be needed to improve medication safety. A prior AHRQ WebM&M interview and its accompanying perspective discuss safety in nursing homes.

SNFs: Opening the Black Box

Save to Library

WebM&M Case December 1, 2013

Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.

Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living.

Save to Library

Fitzgibbon M, Lorenz R, Lach H. J Gerontol Nurs. 2013;39:22-9; quiz 30-1.

Medication discrepancies were extremely common in geriatric patients at the time of discharge from hospital to assisted living facilities, highlighting the need for better medication reconciliation in this situation.

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

Save to Library

Cambridge, MA: Institute for Healthcare Improvement; June 2012.

This series, developed in conjunction with the STAAR initiative, provides tactics and resources to improve transitions across various care settings.

The Safety and Quality of Long Term Care

Save to Library

WebM&M Case September 1, 2011

Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

Improving Communication During Transitions of Care.

Save to Library

Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404097.

This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.

Save to Library

Gandara E, Moniz T, Ungar J, et al. J Hosp Med. 2009;4.

Documentation of important care transition information, such as medication changes and pending test results, was often lacking when patients were transferred from a hospital to a rehabilitation facility.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Save to Library

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.

Clinical Handover: Critical Communications.

Save to Library

Med J Aust. 2009;190(s11):s108-s157.

This supplement discusses Australian efforts to improve handover safety with emphasis on flexible standardization, communication improvement, and information sharing tactics.

Medication discrepancies upon hospital to skilled nursing facility transitions.

Save to Library

Tjia J, Bonner A, Briesacher BA, et al. J Gen Intern Med. 2009;24:630-5.

Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to medication errors, as they are often elderly, have multiple chronic illnesses, and take multiple medications. In this study, medication discrepancies (among the hospital discharge summary, SNF referral form, and SNF admission orders) were the rule rather than the exception. Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants, and hypoglycemic agents, which have been linked to serious medication errors in elderly patients. While The Joint Commission has mandated medication reconciliation for long-term care facilities as part of the 2009 National Patient Safety Goals, the authors note that many SNFs do not maintain Joint Commission accreditation, implying that state or national regulations may be needed to improve medication safety across the hospital–SNF transition.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site