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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
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.
Furukawa MF, Spector WD, Limcangco R, et al. J Am Med Inform Assoc. 2017;24:729-736.
Electronic health records have both safety benefits and unintended consequences. This analysis used data from the 2010–2013 Medicare Patient Safety Monitoring System to compare the incidence of in-hospital adverse events among hospitals that did and did not meet meaningful use requirements for health information technology (IT), according to the Healthcare Information Management Systems Society Analytics Database. Investigators found that hospitals that met meaningful use criteria also reported fewer adverse events. Although the study design does not establish a causal relationship between implementation of health IT and the decline in adverse events, the authors argue that these advances in health IT contributed to this patient safety improvement.
Furukawa MF, Eldridge N, Wang Y, et al. J Patient Saf. 2020;16:137-142.
Electronic health record (EHR) adoption was widely spurred by an assumption that it would improve patient safety. Although research suggests that EHRs have had an overall positive effect, unexpected consequences have occurred along the way and many problems remain. This retrospective study compared adverse events among patients in hospitals with fully electronic EHRs to those without such EHRs in place. After controlling for patient and hospital characteristics, patients exposed to a fully electronic EHR had 17% to 30% lower odds of having an adverse event. A recent PSNet interview with Dr. Robert Wachter discussed the role of health information technology in patient safety.
King J, Patel V, Jamoom EW, et al. Health Serv Res. 2014;49:392-404.
This survey of more than 1700 physicians in ambulatory practice found generally positive perceptions of electronic health records (EHRs), with approximately 80% reporting that EHRs enhanced the overall quality of care for patients. Respondents also noted safety benefits, with two-thirds reporting that the EHR alerted them to a potential medication error.
Hsiao C-J, Jha AK, King J, et al. Health Aff (Millwood). 2013;32:1470-7.
This survey found that by 2012, 72% of ambulatory-based physicians in the United States had implemented some form of electronic health record and 40% were using computerized provider order entry. These figures represent a substantial increase over the past several years.
DesRoches CM, Charles D, Furukawa MF, et al. Health Aff (Millwood). 2013;32:1478-85.
Despite considerable federal financial incentives intended to promote electronic health record (EHR) use, as of 2012 only 42.2% of hospitals in the United States had implemented a system that met federal "meaningful use" criteria (which include use of computerized provider order entry with decision support). Rural and nonteaching hospitals were less likely to have implemented an EHR compared with larger urban hospitals.
Wolf MS, King J, Jacobson K, et al. J Gen Intern Med. 2012;27:1587-93.
Overdose of acetaminophen—a commonly used over-the-counter medication—is the leading cause of acute liver failure in the United States, with the majority of cases being unintentional. Prior studies have shown that patients with limited health literacy frequently misunderstand dosing instructions for prescription medications, and this study examined the frequency with which adult patients misunderstood dosing instructions for acetaminophen. Patients were provided with actual bottles of medications and asked to demonstrate how many pills they could take during a day, alone or in combination with other analgesics. Under these simulated conditions, nearly half the patients would have overdosed either by exceeding the recommended daily dose of acetaminophen or by combining two acetaminophen-containing products. An AHRQ WebM&M commentary discusses a case of liver injury caused by incorrect dosing of acetaminophen.
Furukawa MF, Raghu TS, Spaulding TJ, et al. Health Aff (Millwood). 2008;27:865-75.
Continued adoption of health information technology (HIT) systems is driven by efforts to improve safety and quality, but unintended consequences of these systems have been reported. This study used a national survey database to analyze the extent of HIT adoption specifically for medication safety. Investigators discovered wide variations across technologies, hospital characteristics, and geographic locations, with an average hospital adopting 2.24 out of 8 HIT applications. The authors were most struck by the association seen between HIT adoption and states' patient safety initiatives, suggesting the impact of state regulation and patient safety centers in facilitating adoption. They also advocate for thoughtful policy and governmental incentives to further foster HIT adoption moving forward.