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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 24 Results
Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.
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.
Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2021;17:e335-e342.
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.
Patterson ES. Hum Factors. 2018;60:281-292.
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.
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.
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.
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.
Middleton B, Bloomrosen M, Dente MA, et al. J Am Med Inform Assoc. 2013;20:e2-8.
The introduction of health information technology (IT) has resulted in various documented improvements in patient safety and care delivery. However, unintended consequences have also emerged, and the potential for health IT to cause harm is now well recognized. This report includes 10 recommendations for research, policy, industry, and clinician users. These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to improve the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide made recommendations concerning safe implementation of electronic health records. A previous AHRQ WebM&M perspective examines the benefits and challenges of available health IT systems.
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.
WebM&M Case November 1, 2008
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.
Hakimzada AF, Green RA, Sayan OR, et al. Int J Med Inform. 2007;77.
This study describes several instances of near misses that occurred due to patient misidentification, such as physicians being unable to access previous test results because—unknown to them—the patient had been assigned a second medical record number. The investigators used human factors analysis to identify the underlying systems issues that contributed to these errors. Previous studies in adult and pediatric inpatients have also identified patient misidentification as a potential contributor to a large number of errors.
Laxmisan A, Hakimzada F, Sayan OR, et al. IntJ Med Inform. 2007;76:801-811.
This study evaluated factors that jeopardize safe decision-making using ethnographic observation and interviews. Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes for attending physicians. Observed gaps in communication resulted from poor information flow complicated by inherent multitasking, shift changes, and other activities such as documentation time and utilization of computer resources. The authors present typical workflow patterns in the ED and provide a summary of interview responses to illustrate the taxing nature of cognitive overload facing the studied clinicians. They conclude that carefully designed technology can minimize the effect that interruptions and handoffs have on patient safety.