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.
The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his passing. This special issue highlights the efforts of the 2022 Eisenberg Award honorees and their impact on improving patient safety and quality. The 2022 award recipients coved here include Jason S. Adelman, MD, MS, and North American Partners in Anesthesia (NAPA).
Khazen M, Sullivan EE, Arabadjis S, et al. BMJ Open. 2023;13:e071241.
Improving diagnostic quality is a patient safety priority. In this study, researchers used audio-recorded encounters, clinical note review, and interviews in order to evaluate a tool assessing key elements of diagnostic quality during clinical encounters. Many elements were reliably included in the clinical note or encounter transcript (e.g., follow-up contingencies, red flags) but other elements were often missing (e.g., psychosocial/contextual information). The researchers found that burnout was more common among physicians recording fewer key diagnostic elements.
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.
Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.
Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.
Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;30:838-845.
Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.
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.
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.
Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.
The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.
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%).
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2023;10:4-8.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.
Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.
Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.
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.
Bradford A, Shahid U, Schiff GD, et al. J Patient Saf. 2022;18:521-525.
Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.