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.
Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Patterson ES, Sillars DM, Staggers N, et al. Jt Comm J Qual Patient Saf. 2017;43:375-385.
Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.
McDonald KM, Su G, Lisker S, et al. Implement Sci. 2017;12:79.
Diagnostic error in the ambulatory care setting is common, particularly with regard to missed or delayed diagnoses of cancer. This study used human factors engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor patients with high-risk conditions and to identify vulnerabilities in the monitoring process that could lead to delayed diagnoses.
Hilligoss B, Mansfield JA, Patterson ES, et al. Jt Comm J Qual Patient Saf. 2015;41:134-143.
Handoffs transfer accountability for a patient from one clinician to another. This commentary proposes a framework for transfers from the emergency department to other units within the hospital that highlights environmental, organizational, and social factors that affect these interactions to augment handover quality.
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. BMJ Qual Saf. 2014;23:483-9.
Researchers performed direct observation of nurse and physician handoff communication to assess their use of interactive questioning, a recommended aspect of this approach. Experienced providers utilized more interactive questioning, and physicians used interactive questioning more often than nurses. These results suggest that providers acquire handoff skills over time and that such techniques may be needed in education for less experienced providers.
Welch SJ, Cheung DS, Apker J, et al. Jt Comm J Qual Patient Saf. 2013;39:279-286.
Discussing how noise and communication failures in the emergency department affect patients and clinicians, this commentary recommends tactics to enhance communication and reduce ambient noise in this setting.
Chipps E, Wills CE, Tanda R, et al. J Nurs Care Qual. 2011;26:302-310.
Low interrater agreement when attempting to retrospectively analyze adverse events is a well-documented problem in the safety literature. This study found relatively poor agreement between registered nurses regarding the severity and preventability of adverse events.
Patterson ES, Wears RL. Jt Comm J Qual Patient Saf. 2010;36:52-61.
Resident work-hour restrictions and The Joint Commission have provided two drivers in recent years for improving patient handoffs. Despite efforts to develop standardized approaches, providers remain concerned about the impact of inadequate handoffs. This study reviewed nearly 400 articles to outline the seven primary functions of handoffs with each tied to a set of different interventions for improvement. The functions included information processing, narratives, accountability, social interaction, and cultural norms. The authors suggest that the diversity in handoff measurement reflects the lack of consensus about the primary purpose of a handoff, and that the definition should avoid an overly narrow construct. An accompanying editorial [see link below] highlights the challenges in developing handoff improvement strategies. A past AHRQ WebM&M commentary discussed a case of a handoff error that led to an adverse event.
Cheung DS, Kelly JJ, Beach C, et al. Ann Emerg Med. 2010;55:171-80.
Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.
Flanagan ME, Patterson ES, Frankel RM, et al. J Am Med Inform Assoc. 2009;16:509-15.
This study found that a patient handoff tool can reliably extract information from the electronic health record, though additional opportunities for improvement were identified. A past AHRQ WebM&M commentary discussed a case of a failed signout process that contributed to a delay in treatment and diagnosis.
Due to lack of communication during shift change, an infant's transfer to a higher level of care is delayed. The infant develops respiratory distress, prompting a call to the rapid response team and transfer to the ICU.
Patterson ES, Cook RI, Render ML. J Am Med Inform Assoc. 2002;9:540-53.
This cross-sectional observational study discovered a number of unintended consequences of bar code medication administration (BCMA) technology implementation and the potential for new paths to adverse drug events. Using ethnographic observation techniques on nearly 70 nurse-BCMA interactions, investigators identified and discuss five negative side effects of the new medication process. Both conceptual and operational frameworks are presented, but the authors point out that their findings do not call for abandoning the technology. They argue that, with implementation of any new technology, redesign and anticipation of unintended effects must be considered. The technique of observation described in this study may serve as a very useful tool for similar technology advances and implementation.
Electronic medical records offer opportunities to generate automatic clinical reminders, a feature believed to improve patient care. This study explored barriers to adoption through several observational and survey techniques. Investigators identified ten barriers to effective use, which included workload, time to remove inapplicable reminders, the use of paper forms, accessibility of workstations, and the presence of resident physician and trainees. Discussion involves detailed account of each barrier and how certain future interventions may address them. The authors advocate using this multiprong methodology to identify barriers to effective use of new information technology.
Saleem JJ, Patterson ES, Militello LG, et al. J Am Med Inform Assoc. 2005;12:438-47.
This observational study identified elements that hinder or support the use of electronic clinical reminders. Barriers included workload issues and a lack of team coordination. Effective placement of workstations and prompt system administrator feedback was found to facilitate the use of computer-generated reminders.