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.
Fanikos J, Tawfik Y, Almheiri D, et al. Am J Med. 2023;136:927-936.
Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.
Desai S, Eappen S, Murray K, et al. Jt Comm J Qual Patient Saf. 2020;46:715-714.
This article describes the implementation of a new system for identifying, communicating, and resolving safety reports pertaining to COVID-19 in one academic tertiary care center through the use of electronic safety reporting systems and daily huddles.
Sivashanker K, Mendu ML, Wickner PG, et al. Jt Comm J Qual Patient Saf. 2020;46:483-488.
This article describes the development of a COVID-19 exposure disclosure checklist which reflects five core competencies for effective disclosure conversations with patients and families. The authors discuss disclosure with persons who have limited English proficiency, undocumented and immigrant patients, and patients with specific health needs.
Wickner PG, Hartley T, Salmasian H, et al. Jt Comm J Qual Patient Saf. 2020;46:477-482.
The authors of this commentary propose a communication checklist for healthcare workers regarding potential health care-associated exposure to COVID-19. Key elements include identifying individuals responsible for communicating with and supporting potentially exposed health care workers; curtailing spread through timely disclosure and transparency; establishing clear guidance for health care workers and management; and providing essential resources for healthcare worker dealing with an exposure, such as peer support or remote work.
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
Mendu ML, Lu Y, Petersen A, et al. BMJ Qual Saf. 2020;29.
This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Her QL, Amato MG, Seger DL, et al. J Am Med Inform Assoc. 2016;23:924-33.
Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.
Keogh C, Kachalia A, Fiumara K, et al. Jt Comm J Qual Saf. 2016;42:186-194.
This quality improvement initiative found that providing measurement, feedback, coaching, and financial incentives led primary care practices to improve medication reconciliation over time. This suggests that multimodal interventions using traditional quality improvement methods can address longstanding safety issues in primary care.
Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124.
Warfarin and other anticoagulant medications place patients, especially elderly ones, at high risk of adverse drug events (ADEs) due to their narrow therapeutic window. This retrospective analysis of anticoagulant-related ADEs at an academic medical center identified the underlying cause of these events and found evidence that a large proportion should be preventable. More than two-thirds of anticoagulant-related ADEs were attributable to medication errors, usually at the medication administration stage. A large proportion of the errors were ascribed to incorrect transcription of orders. The persistent incidence of transcription errors in this study is especially surprising given that the hospital in question already had a computerized provider order entry (CPOE) system. Fully electronic closed-loop medication systems, which integrate CPOE, barcoding, and electronic medication administration records, hold promise as a means of reducing both transcribing and administration errors.
Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-6.
Electronic prescriptions offer significant safety advantages in the outpatient setting, in part through use of decision support systems such as standardized dosage and frequency instructions. However, this study found that allowing clinicians to enter free-text instructions in addition to standardized instructions introduced a significant risk of error, particularly for medications already considered high risk. This study adds to a growing body of literature on the unintended consequences of computerized order entry and electronic prescribing.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Fanikos J, Cina J, Baroletti S, et al. Am J Cardiol. 2007;100:1465-9.
This study noted two adverse drug events (ADEs) per 100 patient admissions in hospitalized cardiac patients. Preventable ADEs most frequently occurred during medication administration, and cardiovascular agents and anticoagulants were the most common drug classes involved. Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between nurses at shift change. The authors advocate for prevention strategies around medication administration and nursing shift changes to reduce the potential for errors.
Cina J, Gandhi TK, Churchill WW, et al. Jt Comm J Qual Patient Saf. 2006;32:73-80.
This study directly observed more than 140,000 medication doses filled at a tertiary academic medical center, reporting an error rate of 3.6%. Of the undetected errors observed, nearly a quarter represented potential adverse drug events (ADEs) with incorrect medications, strength, and dosage form being the most common. The authors provide a detailed account of the classification and types of dispensing errors with a discussion of contributing factors.
Kucher N, Koo S, Quiroz R, et al. N Engl J Med. 2005;352:969-77.
With reported underutilization of deep-vein thrombosis (DVT) prophylaxis, this study examined the impact of a computer alert program to increase use and reduce the incidence of DVT. Investigators linked a software program to an existing patient database to identify patients at risk who were not receiving prophylaxis. The provider involved then received an alert and was given a number of appropriate options. Results demonstrated increased use of both mechanical and pharmacologic prophylaxis, as well as decreased incidence of DVT and pulmonary emboli. The authors conclude that use of electronic alerts in institutions with available information technology can lead to improved care.