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.
Emani S, Rodriguez JA, Bates DW. J Am Med Inform Assoc. 2023;30:995-999.
Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.
Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.
Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.
Gandhi TK. Jt Comm J Qual Patient Saf. 2023;49:235-236.
… Jt Comm J Qual Patient Saf … Safety event reporting is a primary method of gathering data to enhance learning from … full picture of gaps in care that could result in harm. … Gandhi T. Now is the time to routinely ask patients about …
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
… New Engl J Med … An accurate understanding of the frequency, severity, … included at least one preventable event and 1% had a severity level of serious or higher. An accompanying … for leadership to prioritize patient safety anew. … Bates DQ, Levine DM, Salmasian H, et al. The safety of …
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): …
Apathy NC, Howe JL, Krevat S, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
… J Patient Saf … Adverse events can be identified through … … Samal L, Khasnabish S, Foskett C, et al. Comparison of a voluntary safety reporting system to a global trigger tool … for identifying adverse events in an oncology population. J Patient Saf. Epub 2022 Jul 21, …
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;10:1844-1855.e3.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels.
… J Patient Saf … Patient safety efforts increasingly seek … “care stories” about their experiences, (3) there was a spectrum of trust between patients and providers , and (4) … for them was important. … Butler JM, Gibson B, Schnock K, et al. Patient perceptions of hospital experiences: …
Syrowatka A, Song W, Amato MG, et al. Lancet Digit Health. 2022;4:e137-e148.
… medication prescribing errors) patient harm. … Syrowatka A, Song W, Amato MG, et al. Key use cases for artificial intelligence … to reduce the frequency of adverse drug events: a scoping review. Lancet Digit Health. 2022;4(2):e137-e148. …
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18:e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;27:88-95.
… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is … about speaking out in hospitals: A qualitative study. J Health Serv Res Policy. Epub 2022 Jan 3. …
Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48:61-64.
… Jt Comm J Qual Patient Saf … Families and caregivers play an … safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver … visitation, both during the pandemic and beyond. … Gandhi TK. Don't go to the hospital alone: ensuring safe, …
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.
Diagnostic errors in the acute care setting can result in increased morbidity and mortality. Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records of patients whose deaths were associated with at least one medical error. Most (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points.