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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 29 Results
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2022;29:909-917.
… health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different … hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list … but not signed), which needs further study. … Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to …
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019;173:979-985.
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Adelman JS, Berger MA, Rai A, et al. J Am Med Inform Assoc. 2017;24:992-995.
Wrong-patient errors can occur during computerized provider order entry, particularly if ordering clinicians have more than one patient record open. Experts have recommended that health systems allow only a single patient record to be open at a time to prevent these errors. This national survey of electronic health record leaders examined whether health systems permit records for multiple patients to be open simultaneously for electronic ordering and documentation. Nearly 200 health systems responded to the survey, and respondents described widely differing practices. Among health systems where clinicians could open multiple patient records at a time, the common justification was to support efficiency. A significant proportion did impose a restriction of working on one patient record at a time, and a smaller group limited clinicians to working with two open patient records only. These results suggest that further study of the optimal number of open patient records is needed to balance safety and efficiency in completing electronic health record work.
WebM&M Case August 21, 2016
… mitigation, and prevention. … Case & Commentary—Part 1: … A 72-year-old woman was admitted to the intensive care unit … [go to PubMed] 3. Patel VL, Zhang J, Yoskowitz NA, Green R, Sayan OR. Translational cognition for decision support in …
WebM&M Case January 1, 2016
… The Case … A 55-year-old man, presented to a primary care physician's … was the registration error noticed. … The Commentary … by Robert A. Green, MD, MPH, and Jason Adelman, MD, MS … … February 2014. [Available at] 5. Salmasian H, Green R, Friedman C, Hripcsak G, Vawdrey D. Are patients with …
Patel VL, Kannampallil TG, Shortliffe EH. BMJ Qual Saf. 2015;24:468-474.
… & safety … BMJ Qual Saf … Cognition has been recognized as a human factor that can contribute to failures in health … train physicians to manage cognitive error once it occurs. A Perspective  interview with Dr. Pat Croskerry explored the …
Murphy DR, Laxmisan A, Reis BA, et al. BMJ Qual Saf. 2014;23:8-16.
… . These delays can lead to poor patient outcomes and are a frequent cause of malpractice lawsuits in the ambulatory … each these triggers were between 58% and 70%, providing a reasonably accurate report of patients that truly lacked … identified better follow-up of abnormal test results as a key area for improving patient safety in the ambulatory …
Smith MW, Giardina TD, Murphy DR, et al. BMJ Qual Saf. 2013;22:1006-13.
In this study, primary care providers frequently relied on extraordinary actions to overcome system barriers in obtaining their patients' timely and safe cancer evaluations. This finding provides evidence that downstream measures, such as timeliness of diagnosis, may fail to detect major system problems.
Middleton B, Bloomrosen M, Dente MA, et al. J Am Med Inform Assoc. 2013;20:e2-8.
… the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide … safe implementation of electronic health records. A previous AHRQ WebM&M perspective  examines the benefits and …
Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-23.
This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.