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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 92 Results
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.
Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.
The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.
Schnock KO, Roulier S, Butler J, et al. J Patient Saf. 2022;18:e407-e413.
Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.
Butler JM, Gibson B, Schnock KO, et al. J Patient Saf. 2022;18:e563-e567.
Patient safety efforts increasingly seek patient input and engagement to improve care. In this qualitative study, patients and families reported on recent hospitalizations and their perceptions of their care and safety. Four main themes were elicited: (1) experiences with safety problems were not unusual, (2) patients and families developed “care stories” about their experiences, (3) there was a spectrum of trust between patients and providers, and (4) having someone advocate for them was important.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6:e470.
Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.
Ni Y, Lingren T, Huth H, et al. JMIR Med Inform. 2020;8:e19774.
Interoperability of smart pumps and electronic health record (EHR) systems can improve clinical data accuracy. This study evaluated the utility of harmonizing EHR data and smart pump records (SPRs) in detecting medication administration errors in one neonatal intensive care unit (NICU). The authors found that compared with medication administration records, dosing discrepancies were more commonly detectable using integrated SPRs, which suggests that this approach may be a more reliable data source for medication error detection.
Gibson B, Butler J, Schnock KO, et al. Patient Educ Couns. 2019;103:741-747.
… accessible for a lay audience. … Gibson B, Butler J, Schnock K, Bates D, et al. Design of a safety dashboard … Patient Educ Couns. 2020;103(4):741-747. DOI: 10.1016/j.pec.2019.10.021 …
Melton KR, Timmons K, Walsh KE, et al. BMC Medical Inform Decis Mak. 2019;19:213.
Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.
Holmgren J, Co Z, Newmark L, et al. BMJ Qual Saf. 2020;29:52-59.
A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Jt Comm J Qual Patient Saf. 2019;45:164-169.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … High reliability industries such as … Randall KH, Slovensky D, Weech-Maldonado R, Patrician PA, Sharek PJ. Self-Reported Adherence to High Reliability …
Classen D, Li M, Miller S, et al. Health Aff (Millwood). 2018;37:1805-1812.
Most health care organizations primarily rely on retrospective techniques such as incident reporting systems to detect and respond to patient harm. Retrospective techniques do not capture a substantial proportion of patient safety events and are not effective for real-time feedback or safety incident prevention. By contrast, electronic health record–based trigger tools detect safety incidents in real time. Investigators developed and piloted the patient safety active management (PSAM) at two large community hospitals. The PSAM employed machine learning and expert clinician review of years of adverse event data to refine the Institute for Healthcare Improvement Global Trigger Tool and distilled this into a real-time risk score for patient safety incidents. The PSAM identified 10 times more safety incidents than were detected through retrospective techniques. It reliably predicted both serious adverse events and mortality. A prior PSNet perspective explored how to leverage electronic health records to enhance safety. The Moore Foundation provides free access to this article.
Weingart SN, Atoria CL, Pfister D, et al. J Patient Saf. 2021;17:e701-e707.
This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.