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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 43 Results
Kahn S, Abramson EL. Arch Dis Child. 2019;104:596-599.
Pediatric patients are particularly vulnerable to medication errors. This review explores efforts to reduce risks of medication mistakes in this patient population and safety improvement strategies such as smart pumps, barcoding systems, and workflow management systems.
Kapadia SN, Abramson EL, Carter EJ, et al. Jt Comm J Qual Patient Saf. 2018;44:68-74.
The Joint Commission requires hospitals to have antimicrobial stewardship programs to prevent harm from antimicrobial overuse. The authors interviewed antimicrobial stewardship program leaders to delineate the qualities of successful programs and future directions for the field. A past WebM&M commentary described the harms associated with inappropriate antibiotic use.
Boockvar K, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.
Inaccurate medication reconciliation leads to medication discrepancies and places patients at risk for adverse drug events. Health information exchange can enhance medication safety through improved access to prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access to a regional health information exchange for patients admitted to a single hospital in the intervention arm and without such information access for patients in the control arm. In the first 10 months of the study, the health information exchange provided access to prescribing information from large hospitals and a pharmacy insurance plan, but only hospital prescribing information was available during the last 21 months because the insurance plan began charging for data. Although researchers found no significant difference between the intervention and control groups with regard to the number of medication discrepancies, patients who underwent medication reconciliation with access to pharmacy insurance data had a higher number of medication discrepancies identified than control patients. They conclude that charging for pharmacy data interrupted the positive effect of health information exchange on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing information led to an adverse drug event.
Ancker JS, Edwards A, Nosal S, et al. BMC Med Inform Decis Mak. 2017;17:36.
Alarm fatigue is an increasingly recognized safety concern. This retrospective cohort study found that primary care clinicians were more likely to override alerts when there were multiple alerts per patient, but overrides were not related to overall workload or repeated exposure to the same alert. The authors recommend reducing the number of alerts per patient to address alarm fatigue.
Pfoh ER, Engineer L, Singh H, et al. J Patient Saf. 2021;17:e121-e127.
Patient safety in ambulatory care is emerging as an area of focus for safety improvement. This review discusses the importance of using near misses as a learning opportunity in outpatient care. The authors describe the design of a near miss registry to collect information on factors that contribute to errors as a way to enable learning and improvement.
Brenner SK, Kaushal R, Grinspan Z, et al. J Am Med Inform Assoc. 2016;23:1016-36.
Health information technology (IT) has had a profound impact on health care. Although health IT has led to efficiency gains and improved safety, unintended consequences remain a concern. In this systematic review, researchers analyzed 69 studies from 2001 through 2012 that examined the use of health IT in a clinical setting and its effect on safety outcomes for patients. About one-third of the studies demonstrated a positive impact of health IT on patient safety outcomes, but many of these focused on the hospital setting, involved a single institution, and looked at decision support or computerized provider order entry. The authors suggest that future studies should focus on other areas in which the impact of health IT remains understudied, such as in outpatient and long-term care settings, and they underscore the need for higher quality research. A recent WebM&M commentary described the unintended consequences of health IT.
Abramson EL, Pfoh ER, Barrón Y, et al. Jt Comm J Qual Patient Saf. 2013;39:545-552.
Computerized provider order entry (CPOE) reduces overall medication error rates, but this effect may depend on effective clinical decision support systems (CDSS). Whereas most previous longitudinal studies of outpatient CPOE have been performed in academic settings, this study examined community-based primary care providers, who actually write the bulk of ambulatory prescriptions. Rates of prescribing errors immediately following CPOE implementation were low, with approximately 6 errors per 100 prescriptions. These rates were sustained at 1 year following implementation. A previous AHRQ WebM&M perspective described the importance of thoughtful application of CDSS for medication prescribing.
WebM&M Case September 1, 2013
… heighten prescribing vigilance and help avert errors. … Erika Abramson, MD, MS … Assistant Professor of Pediatrics … and use monitoring … ErikaRainuAbramsonKaushalLErika L AbramsonRainu Kaushal
Abramson EL, Malhotra S, Osorio N, et al. J Am Med Inform Assoc. 2013;20:e52-8.
Many institutions are now moving from relatively unsophisticated electronic health records (EHRs) to more advanced systems. This transition can pose safety hazards; a previous article demonstrated that replacing an older EHR with a new system resulted in a higher incidence of some types of prescribing errors. However, this follow-up study found that prescribing errors consistently decreased as users became more familiar with the new system and as the system was refined. Prior studies have also shown that at least 1 year of use is required to obtain the safety benefits of EHRs. The article provides an excellent example of the ongoing monitoring and adaptation required to effectively implement EHRs.
Winters BD, Weaver SJ, Pfoh ER, et al. Ann Intern Med. 2013;158:417-25.
Rapid response systems (RRSs) are somewhat effective at preventing cardiorespiratory arrest outside the intensive care unit, according to this AHRQ-funded systematic review published as part of a patient safety supplement in the Annals of Internal Medicine. The review also identifies barriers and facilitators to effective implementation of RRSs in different contexts.
Weaver SJ, Lubomksi LH, Wilson RF, et al. Ann Intern Med. 2013;158:369-74.
This systematic review—part of the AHRQ Making Health Care Safer II report—found some evidence that interventions, such as teamwork training, executive walk rounds, and structured communications approaches, can improve safety culture, especially when bundled together as a multicomponent intervention.
Abramson EL, Bates DW, Jenter CA, et al. J Am Med Inform Assoc. 2012;19:644-8.
This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.
WebM&M Case September 1, 2011
Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.
Abramson EL, Malhotra S, Fischer K, et al. J Gen Intern Med. 2011;26:868-74.
The implementation of new computerized provider order entry (CPOE) systems can have unintended consequences, including adverse clinical outcomes. As CPOE systems evolve, health systems are beginning to transition from older versions (with only limited decision support capabilities) to more sophisticated systems. This analysis of a primary care practice that underwent such a transition found fewer overall prescribing errors with a newer system. However, this improvement was largely due to the new system's ability to prevent "do-not-use" abbreviations in prescriptions; the incidence of other types of prescribing errors actually increased for the first 3 months after implementation. Even with experienced CPOE users, novel systems evidently have the potential to adversely affect patient safety.
Kaushal R, Kern LM, Barrón Y, et al. J Gen Intern Med. 2010;25.
Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.
Lemer C, Bates DW, Yoon CS, et al. J Patient Saf. 2009;5:168-75.
The majority of adverse drug events in children can be ascribed to incorrect medication administration by parents. Education around medications by physicians or pharmacists would seem to be an effective way of preventing such errors, but this study found that parents received such advice in only a minority of cases. Parents who received medication education were not statistically less likely to commit a medication administration error. The authors interpret this finding as an indication that medication counseling was likely of poor quality even when it was given. A case of an inadvertent medication overdose in an infant due to inadequate parental education is discussed in this AHRQ WebM&M commentary.