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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.

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Displaying 1 - 20 of 22 Results
Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.
Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.
Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
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.
Achilleos M, McEwen J, Hoesly M, et al. Am J Health Syst Pharm. 2020;77.
Pharmacists are critical to ensuring safe transitions between acute care and skilled nursing facilities (SNFs). This retrospective study evaluated the frequency of missed doses of high-risk medications after hospital-to-SNF transfers and found that 60% of first doses of high-risk medications were given after the scheduled administration time. After implementation of a medication order process including pharmacist-led medication reconciliation, the average delay in medication administration decreased significantly. 
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.
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.
Callinan SM, Brandt NJ. J Gerontol Nurs. 2015;41:8-13.
Highlighting risks associated with transitions of older patients between the emergency department and long-term care, this commentary describes strategies to improve communication, and subsequently medication safety, as these patients move from one care environment to another.
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.
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.
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.
Boling PA. Clin Geriatr Med. 2009;25:135-48, viii.
This article reviews the literature on transitions of care, discusses interventions, and suggests that transitional care processes supported by effective home care programs can reduce rehospitalization.
Boockvar KS, Liu S, Goldstein N, et al. Qual Saf Health Care. 2009;18:32-6.
Posthospital medication discrepancies are a known safety issue, with the resulting errors stemming from unintended events as well as from the broader transitions in care. Medication reconciliation was named as a 2005 National Patient Safety Goal in part to address these concerns at various transition points in a patient's hospitalization. This study analyzed more than 200 patients' medication records during transitions between acute hospital and their nursing homes to determine the predictive value of medication discrepancies for adverse drug events (ADEs). Investigators found that the drug classes at highest risk for discrepancy-related ADEs were opioid and nonopioid analgesics, providing a specific target for future intervention. A past AHRQ WebM&M commentary discussed the importance of medication reconciliation and barriers to successful adoption, and suggested best practices.
Delate T, Chester EA, Stubbings TW, et al. Pharmacotherapy. 2008;28:444-52.
Inadvertent medication discrepancies are common at the time of transitions in care, and medication reconciliation is being widely advocated as a method of preventing medication errors in this setting. This controlled trial used clinical pharmacists to identify and intervene on medication discrepancies after patients were discharged from skilled nursing facilities. Patients receiving the pharmacist intervention had significantly reduced mortality in follow-up, although the investigators were not able to confirm if this reduction was due to prevention of medication errors. Prior research in this area has also documented the value of clinical pharmacists in preventing medication errors during care transitions.
Scott-Cawiezell J, Pepper GA, Madsen RW, et al. Clin Nurs Res. 2007;16:72-8.
This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.
WebM&M Case February 1, 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.