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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 - 8 of 8 Results
Perspective on Safety March 29, 2023
… to notifications. This can lead to more medical errors. As a testament to the significance of this topic in recent … all relevant articles on PSNet and consulted with Dr. A Jay Holmgren, PhD, and Dr. Susan McBride, PhD, subject matter … Sittig DF, Sengstack P, Singh H. Guidelines for US hospitals and clinicians on assessment …

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Kutza J-O, Hübner U, Holmgren AJ, et al. Stud Health Technol Inform. 2022:885-889.
… experts have raised patient safety concerns . Based on a literature review and expert feedback, this article … IT implementation and high quality, safe patient care. … Kutza JO, Hübner U, Holmgren AJ, et al. Patient safety informatics: criteria …
Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12:153-163.
Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.
Classen DC, Holmgren AJ, Co Z, et al. JAMA Netw Open. 2020;3.
Researchers measured the safety performance of electronic health record (EHR) systems using simulated medication orders that can lead to adverse events or death in order to evaluate how well the systems identified these errors, and the mitigating effect of computerized physician order entry and clinical decision support (CDS) tools. Safety performance increased moderately over the 10-year study period but there was considerable variation in performance based on the level of decision support (basic or more complex) and EHR vendor; safety risks persist despite EHR implementation.
Holmgren J, Patel V, Adler-Milstein J. Health Aff (Millwood). 2017;36:1820-1827.
Barriers to interoperability across health information systems may compromise patient safety by preventing sharing of clinical information necessary for optimal patient care. Researchers found that hospitals' engagement in sharing of patient information across four domains of interoperability increased only modestly from 24.5% of hospitals in 2014 to 29.7% of hospitals in 2015.