Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 30 Results
Leung AA, Denham CR, Gandhi TK, et al. J Patient Saf. 2015;11:89-99.
Barcode technology has been advocated as a strategy to reduce medication errors. This narrative review explored barcoding solutions applied in various care settings and found that they resulted in notable reductions of transcription, dispensing, and administration errors. The authors recommend standards for successful implementation of barcode technology systems.
Nanji KC, Rothschild JM, Boehne JJ, et al. J Am Med Inform Assoc. 2014;21:481-6.
Computerized provider order entry (CPOE) systems have been widely implemented to prevent adverse drug events due to prescribing errors. This direct observation and interview study in an outpatient pharmacy setting describes changes in practice as a result of electronic prescribing. Consistent with prior studies investigating unintended consequences of CPOE, researchers identified new errors associated with electronic prescribing, as well as potential methods to reduce adverse drug events. To improve safety, the authors recommend developing systems to track abandoned prescriptions, offering incentives for pharmacies to utilize electronic prescribing, and enhancing the interface between electronic health record and pharmacy computer systems to decrease manual entry, limit duplicated prescriptions, and expedite clarification requests. A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong patient and deleted it, mistakenly assuming it would cancel the order.
Kale A, Keohane C, Maviglia SM, et al. BMJ Qual Saf. 2012;21:933-8.
Efforts to improve medication safety focus on preventing potential adverse drug events (ADEs, medication errors with a high likelihood of resulting in patient harm), under the assumption that preventing these near misses will reduce medication-related harm. However, the proportion of potential ADEs that result in actual preventable ADEs is controversial. This analysis of data from a prior study of medication administration errors found that 7.5% of potential ADEs resulted in actual clinical harm for patients. The authors point out that this apparently low incidence of preventable ADEs would still result in more than 4000 preventable ADEs every year at a 700-bed hospital.
Schnipper JL, Gandhi TK, Wald JS, et al. J Am Med Inform Assoc. 2012;19:728-34.
Medication errors are likely the most common safety problem in primary care, and ensuring accurate medication reconciliation remains a challenge in the outpatient setting. This innovative cluster-randomized trial, conducted in a health system with integrated electronic medical records (EMRs), used a novel method of engaging patients in safety to attempt to reduce medication error risk. Patients in the intervention completed their own medication lists, which could then be viewed and reconciled within the EMR by their physicians. Patients who participated had a lower incidence of medication discrepancies and fewer potential adverse drug events than control patients. Although preliminary, the study results point toward further ways in which EMRs can enhance safety by improving patient–physician communication.
Dalal A, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-8.
Management of tests pending at discharge (TPAD) is a continued focus of safety efforts. Although improved discharge summaries address certain gaps in communication, additional strategies are still required. This study describes the development and implementation of an automated TPAD email notification system. The goal was to push results to the discharging inpatient provider and facilitate communication with primary care providers. Discharging providers received approximately 1.6 email notifications per discharged patient and were satisfied overall with the new system. The authors reflect on key elements of improving the system, which include further refinement of the computer logic to minimize alert fatigue and careful attention to assigning accountability for acting on the notifications. A past AHRQ WebM&M commentary discussed an adverse outcome that resulted from poor test follow-up after hospital discharge.
Love JS, Wright A, Simon SR, et al. J Am Med Inform Assoc. 2012;19:610-4.
Electronic health records (EHRs) are increasingly being implemented in both inpatient and outpatient environments, and a growing body of data indicates that EHR implementation is associated with improved quality of care. This survey of more than 500 physicians who regularly used EHRs found that nearly one-third believed that EHRs could actually increase the potential for errors—a belief that has empirical support—although only a very small proportion had actually experienced such an error. Physicians who were concerned about the safety implications of EHRs were also more likely to report dissatisfaction with their practice setting. Implementation of EHRs can significantly disrupt clinicians' work environment, and prior studies have shown that one full year of experience with EHRs is required for providers to view such systems positively. These findings have important implications for organizations planning the implementation process for new EHRs.
Nanji KC, Rothschild JM, Salzberg C, et al. J Am Med Inform Assoc. 2011;18:767-73.
Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the lack of computerized systems that promote safe prescribing. This retrospective cohort study analyzed nearly 4000 computer-generated prescriptions over a 4-week period and found a 12% error rate; 35% were considered potential adverse drug events. The error rates varied for different computerized systems (ranging from 5% to 38%) with omitted information the most common error type (60%). The findings suggest that implementing e-prescribing solutions requires more than simply adopting a computerized system. Careful attention is required to assure safe processes and functionality.
Dalal A, Poon EG, Karson A, et al. J Hosp Med. 2011;6:16-21.
Describing the experience of one hospital's implementation of an electronic system to help track and manage tests pending at hospital discharge, this study describes the surprisingly large number of barriers to developing safe and effective systems to deal with such tests at discharge.
Poon EG, Keohane C, Yoon CS, et al. New Engl J Med. 2010;362:1698-1707.
Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Barcoding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a closed-loop system that combined CPOE, barcoding, and an electronic medication administration record in an academic medical center and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.
Nanji KC, Cina J, Patel N, et al. J Am Med Inform Assoc. 2009;16:645-50.
This case study reports on one large academic hospital's experience implementing a pharmacy bar code scanning system for medication dispensing. The authors describe workarounds that emerged and share strategies to address process improvement, technology issues, and staff resistance to the new system.
Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-80.
Attempts to reduce medication discrepancies in hospitalized patients have been hampered by a lack of proven medication reconciliation strategies. In this cluster-randomized trial, a previously described electronic medication list that required input from nurses, physicians, and pharmacists was implemented at two academic hospitals. The tool resulted in a significant reduction in potential adverse drug events at discharge. However, potential drug errors still occurred at a rate of one per patient even after implementation. The intervention was more successful at preventing medication discrepancies among high-risk patients. This study is one of the first randomized trials of a medication reconciliation intervention, and points the way toward identifying medication reconciliation tools that are widely applicable.
El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-8.
Less than 20% of ambulatory practices in the United States utilize electronic health records (EHRs). Uptake has been limited by cost issues and concern about the impact of EHRs on clinician workflow. This survey evaluated clinicians' perceptions of a newly implemented electronic medical record in three primary care clinics. Although initially clinicians felt that the EHR resulted in longer patient visits and increased the time spent documenting, by 1 year after implementation, clinicians felt that the EHR improved their ability to follow up on test results and communicate with other providers, and contributed to higher quality care overall. Importantly, these perceived advantages emerged only after 1 full year of using the new system.
Poon EG, Keohane CA, Bane A, et al. JONA: The Journal of Nursing Administration. 2008;38.
Implementation of a barcode medication administration system was associated with an increase in the time nurses spent in direct patient care and did not increase the amount of time devoted to medication administration. Proper integration of information technology into provider workflow was the subject of a Joint Commission Sentinel Event Alert.
Keohane CA, Bane AD, Featherstone E, et al. J Nurs Adm. 2007;38:19-26.
Adoption of new technology, including bar-coding systems and electronic medication administration records, is viewed as a method to improve medication administration safety. However, unintended consequences from new technology implementation have been reported. This AHRQ-supported time–motion study observed and characterized typical nursing workflow and discovered that medication administration is the most time-consuming task, followed by communication and direct care of patients. As technology creates new workflow and processes, the authors advocate for careful implementation, as increased time in one activity is certain to jeopardize and decrease time available to complete other and equally important aspects of nursing care.
WebM&M Case September 1, 2007
Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.