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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 - 17 of 17 Results
Classen DC, Longhurst CA, Davis T, et al. JAMA Netw Open. 2023;6:e2333152.
Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.
Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;30:838-845.
Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.
Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.
… an increasing range of health care situations to address a variety of care needs. This commentary examines the impact … , and on the limitations of AI that affect reliability. … Classen DC, Longhurst C, Thomas EJ. Bending the patient safety curve: how much can …
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.
Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12:153-163.
Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.
Co Z, Holmgren AJ, Classen DC, et al. J Am Med Inform Assoc. 2020;27:1252-1258.
Using data from the Computerized Physician Order Entry (CPOE) Evaluation Tool, this study compared hospital performance against fatal orders and nuisance orders. From 2017 to 2018, overall performance increased and fatal order performance improved slightly; there was no significant change in nuisance order performance; however, these results indicate that fatal alerts are not being prioritized and that over-alerting in some cases may be contributing to alert fatigue.
Classen DC, Holmgren AJ, Co Z, et al. JAMA Netw Open. 2020;3.
Researchers measured the safety performance of electronic health record (EHR) systems using simulated medication orders that can lead to adverse events or death in order to evaluate how well the systems identified these errors, and the mitigating effect of computerized physician order entry and clinical decision support (CDS) tools. Safety performance increased moderately over the 10-year study period but there was considerable variation in performance based on the level of decision support (basic or more complex) and EHR vendor; safety risks persist despite EHR implementation.
Classen DC, Griffin FA, Berwick DM. Ann Intern Med. 2017;167.
Electronic health records have been widely adopted in both inpatient and outpatient settings. This commentary suggests that health information technology provides health care with an opportunity to optimize patient safety measurement in hospitals and that barriers such as data collection burden, mismatched definitions, and ineffective methods of tracking patient harm can be addressed through robust electronic health record design and use.
Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.
… in CPOE systems, this article reports on development of a list of several interactions that should require hard stops (to essentially prevent co-prescribing). Developing a standardized approach to displaying drug–drug interaction …
Classen D, Resar RK, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.
Despite numerous studies over the past three decades, one fundamental patient safety question remains controversial: what proportion of hospitalized patients are harmed by medical care? Prior estimates range from approximately 3% to nearly 17%, but this study found that nearly one-third of patients experienced an adverse event during hospitalization. This study used the Institute for Healthcare Improvement's Global Trigger Tool to detect adverse events and also found that this trigger tool identified significantly more adverse events than voluntary reporting or the AHRQ Patient Safety Indicators. An important caveat is that this study did not assess whether the adverse events detected were preventable. Nevertheless, the results do raise the concern that adverse events remain common despite enhanced safety efforts. The challenges of accurately measuring patient safety events were discussed in an AHRQ WebM&M perspective.
Classen DC, Lloyd RC, Provost LP, et al. J Patient Saf. 2008;4.
Trigger tools have proved to be an effective method of screening for adverse events, with past research demonstrating their utility in the intensive care unit and pediatric hospitals. This study outlines the Institute for Healthcare Improvement Global Trigger Tool methodology and evaluates a refined process to improve the interrater reliability of the tool in practice. The authors found that a high level of interrater reliability was possible with well-trained primary (nonphysician) and secondary (physician) reviewers in this modified two-step approach.
Resar RK, Rozich JD, Simmonds T, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;32.
This study describes the use of a focused chart review method centered around identification of triggers associated with adverse events (AEs). Non-physician reviewers at 54 hospitals screened charts for evidence of 23 clinical events, such as chest tube insertion, code status change, or readmission to the intensive care unit (ICU). If any of these triggers were present, the relevant portion of the chart was reviewed using methodology similar to the Harvard Medical Practice Study, and a physician confirmed the presence and severity of any AE identified. The authors found a rate of 11.3 AEs per 1000 patient-days, consistent with prior research, although this includes both preventable and non-preventable AEs. The authors state that using this focused review process to screen for AEs in the ICU can provide data to use in appropriately targeting patient safety measures.