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.
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
… UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying … in e-prescribing system decision making. … Sheikh A, Coleman J, Chuter A, et al. Programme Grants Appl Res. 2022;10(7): 1-196. …
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.
The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.
Avery AJ, Sheehan C, Bell BG, et al. BMJ Qual Saf. 2021;30:961-976.
Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.
Carson-Stevens A, Campbell S, Bell BG, et al. BMC Fam Pract. 2019;20:134.
Most patient safety research has focused on tertiary care or specialty care settings, but less is known about safety in primary care settings and there is no clear definition of patient safety incidents and harm occurring in these settings. The authors convened a panel of family physicians and used a consensus method to define “avoidable harm” within family practice. Most scenarios found to be avoidable and included in the proposed definition involved failure to adhere to evidence-based practice guidelines, lack of timely intervention, or failure in administrative processes, such as referrals or procedures for following up on results.
Fahrni ML, Azmy MT, Usir E, et al. PLoS One. 2019;14:e0219898.
In this prospective study involving 301 older patients admitted to 3 hospitals, researchers used the STOPP and START criteria to identify inappropriate prescribing and adverse drug events. Inappropriate prescribing was detected in 59% of patients and potentially inappropriate medications in 35% of patients. The use of inappropriate medications was associated with an increased odds of an adverse drug event.
Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in this special issue explore various facets of health care quality and safety improvement in the care of women and expectant mothers. Topics covered include the patient experience, safety culture, disparities, program implementation, and the patient's role in safety.
Schiff G, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
When patients and caregivers report adverse events, they may identify unique issues that other reporting systems do not capture. The authors propose adjustments to AHRQ's Common Formats for safety event reporting that allow patients and caregivers to more effectively report adverse events. An Annual Perspective emphasized the value of patient adverse event reporting in larger efforts to engage patients in their safety.
Collins SA, Couture B, Smith A, et al. J Patient Saf. 2020;16:e75-e81.
Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.
Pontefract SK, Hodson J, Slee A, et al. BMJ Qual Saf. 2018;27:725-736.
… decision support at three hospitals in England. In a sample of 2422 patients, the overall error rate decreased … the error rate did not change because an increase in a specific insulin prescribing error counterbalanced all … even between the two systems implementing the same CPOE. A PSNet perspective synthesized lessons for assessing …
Cresswell K, Lee L, Mozaffar H, et al. Health Serv Res. 2017;52:1928-1957.
… such as implementation plans. Their analysis demonstrated a need for ongoing platform improvement (including bug fixes … staff over time, not just prior to implementation. In a previous PSNet interview , Dr. Robert Wachter discussed the …
Khalil H, Bell BG, Chambers H, et al. Cochrane Database Syst Rev. 2017;10:CD003942.
This systematic review examined physician-level and organizational-level interventions to improve outpatient medication safety. Existing interventions such as clinical decision support to identify high-risk patients, pharmacist medication review, and educational interventions for prescribers did not prevent medication-related emergency department visits, hospitalizations, or deaths. These results highlight the challenge of reducing serious adverse drug events in outpatient care.
Cooper J, Edwards A, Williams H, et al. Ann Fam Med. 2017;15:455-461.
… … Ann Fam Med … Poor safety culture has been identified as a barrier to incident reporting . Researchers analyzed a sample of family practice patient safety incident reports … using incident reports to improve safety requires a shift to blame-free culture. …
Cooper A, Edwards A, Williams H, et al. Age Ageing. 2017;46:833-839.
According to this mixed-methods analysis of 8 years of data, the most common voluntarily reported incidents involving older primary care patients in England and Wales were related to medication errors and inadequate communication between providers. Many of these errors occurred during the transition home after hospital discharge. These data provide targets for further research to develop methods for improving safety in ambulatory care.