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.
Emani S, Rodriguez JA, Bates DW. J Am Med Inform Assoc. 2023;30:995-999.
Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.
Gandhi TK. Jt Comm J Qual Patient Saf. 2023;49:235-236.
Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.
Schnock KO, Garber A, Fraser H, et al. Jt Comm J Qual Patient Saf. 2023;49:89-97.
Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.
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.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;10:1844-1855.e3.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels.
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.
Syrowatka A, Song W, Amato MG, et al. Lancet Digit Health. 2022;4:e137-e148.
The near ubiquitous use of electronic health records has increased interest in using artificial intelligence (AI) to detect errors, including preventable adverse drug events (ADEs). This scoping review identified 78 studies of AI conducted since 1998, and identified promising areas where AI could be used to predict (e.g., therapeutic response) or detect (e.g., medication prescribing errors) patient harm.
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18:e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.