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.
Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing definitions for drug shortages and the harms that can occur due to drug shortages (e.g., medication errors, treatment delays, undertreatment). Part Two discusses trends in drug shortages, the causes of drug shortages, and potential solutions.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Coleman C, Birk S, DeVoe J. JAMA Intern Med. 2023;183:753-754.
Low personal health literacy is associated with increased post-discharge adverse events and health inequities. This commentary describes organizational strategies to improve health literacy, including elimination of jargon in written and spoken communications and assessment of health professionals’ patient-centered communication tools.
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.
Crunden EA, Worsley PR, Coleman SB, et al. Int J Nurs Stud. 2022;135:104326.
Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.
Acorda DE, Bracken J, Abela K, et al. Jt Comm J Qual Patient Saf. 2022;48:196-204.
Rapid response (RR) systems are used to improve clinical outcomes and prevent transfer to ICU of patients demonstrating signs of rapid deterioration. To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation After Critical Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred within 24 hours of the RR. These reviews identified opportunities for systemwide improvements.
Patterson ME, Bollinger S, Coleman C, et al. Res Social Adm Pharm. 2022;18:2830-2836.
… or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest … conditions or pain. … Patterson ME, Bollinger S, Coleman C, et al. Medication discrepancy rates and sources … Res Social Adm Pharm. 2022;18(5):2830-2836. doi: 10.1016/j.sapharm.2021.06.013 …
In 2017, the World Health Organization (WHO) introduced the third Global Patient Safety Challenge, Medication Without Harm. Interviews, focus groups, and document analysis were conducted at four UK hospitals to evaluate how they were addressing the domains and priority areas laid out in the WHO’s Patient Safety Challenge. Although all areas were addressed, additional focus is needed on patient and public involvement, transitions of care, and polypharmacy.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148:e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
… J Emerg Med … Naloxone administration in inpatient and … the emergency department (ED). … Maloney LM, Alptunaer T, Coleman G, et al. Prehospital naloxone and emergency … department adverse events: a dose-dependent relationship. J Emerg Med. Epub 2020 Sept 26. doi: 10.1016/j.jemermed.2020.07.009 …
Coleman JJ, Manavi K, Marson EJ, et al. Postgrad Med J. 2020;96:392-398.
Many COVID-19 patients present with respiratory symptoms, but others may present with atypical symptoms (e.g., delirium, smell and taste dysfunction, cardiovascular features). This article summarizes the evidence regarding these atypical presentations and the importance of physicians considering conditions which can “mimic” COVID-19 as part of the differential diagnoses in order to avoid diagnostic uncertainty and diagnostic errors.
Medication errors present challenges to patient safety worldwide. Vulnerabilities in the medication-use process are exacerbated by the need to navigate comorbidities in older patients and the general complexity of care. This review examines prescribing concerns and highlights three areas of focus to improve safety: engagement with patients and families as partners in decision making, care coordination, and application of system approaches to support medication safety.
The unintended consequences of computerized provider order entry and clinical decision support are well-described. Researchers conducted focus groups with pharmacists and physicians at two acute care hospitals in England and found that both computerized provider order entry and clinical decision support increased different aspects of workload for pharmacists and providers while electronic messaging capability yielded some improvements in interprofessional communication.
Katlic MR, Coleman JA, Russell MM. JAMA. 2019;321:449-450.
High-risk industries like aviation employ policies to require that practitioners retire from risky work at a certain age. This commentary advocates for individual rather than general approaches to assessing abilities of aging surgeons to practice safely.
Pontefract SK, Hodson J, Slee A, et al. BMJ Qual Saf. 2018;27:725-736.
Although computerized provider order entry (CPOE) reliably reduces medication errors, clinical decision support has more varied impact on safety outcomes. System complexity, insufficient emphasis on human factors engineering, and alert fatigue limit utility of clinical decision support. This study rigorously examined medication error rates before and after implementation of CPOE with clinical decision support at three hospitals in England. In a sample of 2422 patients, the overall error rate decreased 20%. At one hospital, the error rate did not change because an increase in a specific insulin prescribing error counterbalanced all other error reduction. All three hospitals implemented clinical decision support, but the type, nature, and efficacy varied markedly, even between the two systems implementing the same CPOE. A PSNet perspective synthesized lessons for assessing electronic health record safety as a whole.
Senior clinicians often elicit respect from their junior colleagues. This respect can affect colleagues' willingness to intervene should they observe poor performance in their role models. This review discusses the need to manage aging surgeons appropriately as a matter of safety. The authors recommend that peer support, confidential skill assessments, and effective policy can help hospitals track changes in surgeon performance to mitigate potential safety problems while preserving the dignity of their clinical staff.
Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.
Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.
Although electronic health records (EHRs) with computerized provider order entry are known to improve medication safety, experts have raised concerns that EHRs adversely affect interprofessional communication by reducing personal interactions among providers. This study examined unidirectional computerized messages from pharmacists and physicians within the EHR. Investigators found that less than half of messages from pharmacists were acknowledged by the prescribing physicians. Among the messages in which pharmacists requested a specific action, physicians completed the action about one-third of the time. Messages were more likely to be acknowledged and acted upon when pharmacists and physicians had an existing working relationship. The authors suggest that EHRs should be better designed to foster interprofessional collaboration. A PSNet perspective highlighted the role of pharmacists in interprofessional care and safety.
Patient safety is recognized as a critical component of medical education. This commentary spotlights the need for faculty development in patient safety and quality improvement. The authors outline roles for individuals, appointments and promotions committees, and organizations to address this challenge.