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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 21 Results
van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Clin Chem Lab Med. 2018;56:2004-2009.
This review article describes drug–laboratory test interactions, in which medications can affect test results and impede diagnosis. Although the quality of studies varies, researchers identified a potential benefit of clinical decision support to inform ordering clinicians about these potential interactions.
Horsky J, Aarts J, Verheul L, et al. Int J Med Inform. 2017;97:1-11.
Prior research has shown that providers frequently override drug interaction alerts, sometimes as a result of alert fatigue. In this study, researchers observed providers as they completed medication orders, addressing both high- and low-severity drug interaction alerts using five distinct electronic health records in two countries. The authors found that providers engaged in complex clinical reasoning prior to declining an alert, balancing various aspects of patient care including safety- and patient-specific factors.
Payne TH, Hines LE, Chan RC, et al. J Am Med Inform Assoc. 2015;22:1243-50.
Clinical decision support alerts can help identify potential drug–drug interactions, but they can also contribute to alert fatigue. This commentary provides recommendations to inform the design of decision support to address drug–drug interactions. The authors suggest that improvement strategies focus on standardizing terminology and visual cues.
Magrabi F, Aarts J, Nohr C, et al. Int J Med Inform. 2013;82:e139-48.
Implementation of health information technology (IT) has presented several unanticipated patient safety issues, particularly related to computerized provider order entry. Health IT vendors generally have a "hold harmless" clause that removes their liability for patient harm due to health IT failures. This review explores patient safety initiatives for health IT systems across six countries, including the United States. Significant gaps in health IT safety initiatives were identified, including inadequate regulatory oversight in the US for these medical devices. The authors conclude that greater standardization and oversight is required to ensure safety for all types of health IT systems. An AHRQ WebM&M interview with Dr. David Bates discusses the benefits and potential risks of health IT.
Phansalkar S, van der Sijs H, Tucker AD, et al. J Am Med Inform Assoc. 2013;20:489-93.
Clinical decision support system medication alerts have the potential to decrease adverse drug events, but physicians ignore many of these repeated warnings. Alert fatigue is particularly common in drug–drug interaction (DDI) alerts, with prior studies reporting override rates of up to 90%. In this study, an expert panel created a list of 33 class-based, low-priority DDIs that do not warrant interruptive alerts. The goal was to devise a standardized list to help reduce alert fatigue across electronic health records. The authors recommend developing a consortium to maintain this list over time. Dr. David Blumenthal discusses DDI alert fatigue and other issues related to medical information technology in an AHRQ WebM&M interview.
van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-8.
Alerts within a computerized provider order entry system were not able to prevent medication errors resulting from drug–drug interactions. The authors hypothesize that the inadequacy of the alerts themselves was responsible for this failure, with problems including an excessive number of false-positive alerts and unclear instructions for preventing drug interactions.
van der Sijs H, Aarts J, van Gelder T, et al. J Am Med Inform Assoc. 2008;15:439-48.
This study examined nearly 2000 drug–drug interaction (DDI) alerts that were overridden by providers and noted differential triggers based on clinician knowledge or specialty. The authors conclude that simply turning off DDI alerts is limited by these differential triggers and inconsistent drug monitoring, which may raise safety concerns that are prevented by the alerts themselves.