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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 - 14 of 14 Results
Vallamkonda S, Ortega CA, Lo YC, et al. Stud Health Technol Inform. 2022;290:120-124.
Prior research has found that electronic health record (EHR) implementation has introduced risks to patient safety. Using data from one hospital’s EHR system, this study reviewed active allergy alerts in patient records and concluded that 37% of those records required reconciliation of allergy information across different areas of the EHR. These findings highlight the need for automated reconciliation algorithms and clinical decision support tools to help clinicians identify potential allergy discrepancies and avoid patient safety risks.
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. 
Mullur J, Chen Y-C, Wickner PG, et al. J Patient Saf. 2022;18:e431-e438.
COVID-19 restrictions and patient safety concerns have greatly expanded the use of telehealth and virtual visits. Through patient satisfaction surveys and patient complaints, this US hospital evaluated the quality and safety of virtual visits in March and April of 2020. Five patient complaints were submitted during this timeframe and overall patient satisfaction remained high. Safety and quality risks were identified (e.g., diagnostic error) and best practices were established.
Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.
… to communicate important information which introduces a patient safety risk .  One healthcare system searched … 131,000 were manually or automatically remediated (e.g., “ latex from back brace” and “gloves” were coded “latex-natural rubber”). … Li L, Foer D, Hallisey RK, et al. Improving allergy …
Myers LC, Blumenthal K, Phadke NA, et al. Jt Comm J Qual Patient Saf. 2021;47:54-59.
Learning from adverse events is a core component of patient safety improvement. These authors developed guidance for the use of peer review protected information (such as voluntary event reports and root causes analyses) in safety research. The guidance aims to ensure that data are handled safely and appropriately while supporting scientific discovery.  
Yang J, Wang L, Phadke NA, et al. JAMA Netw Open. 2020;3:e2022836.
Artificial intelligence can support improved patient safety outcomes. This study found that a deep learning model can accurately and efficiently identify allergic reactions in hospital safety reports and can potentially enable real-time event surveillance and system improvement.  
Sivashanker K, Mendu ML, Wickner PG, et al. Jt Comm J Qual Patient Saf. 2020;46:483-488.
… Patient Saf … This article describes the development of a COVID-19 exposure disclosure checklist which reflects five … with specific health needs. … Sivashanker K, Mendu ML, Wickner P, et al. Communication with patients and families … health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure. Jt Comm J Qual Patient …
Wickner PG, Hartley T, Salmasian H, et al. Jt Comm J Qual Patient Saf. 2020;46:477-482.
The authors of this commentary propose a communication checklist for healthcare workers regarding potential health care-associated exposure to COVID-19. Key elements include identifying individuals responsible for communicating with and supporting potentially exposed health care workers; curtailing spread through timely disclosure and transparency; establishing clear guidance for health care workers and management; and providing essential resources for healthcare worker dealing with an exposure, such as peer support or remote work.
WebM&M Case June 1, 2019
Transferred to the emergency department from the transfusion center after becoming unresponsive and hypotensive, an elderly man with signs of sepsis is given incomplete and delayed antimicrobial coverage due to a history of penicillin allergy. Neither gram-negative nor anaerobic coverage were provided until several hours later, and the patient developed septic shock.
Wong A, Plasek JM, Montecalvo SP, et al. Pharmacotherapy. 2018;38:822-841.
Natural language processing (NLP) can efficiently analyze large narrative data sets to identify adverse events. Exploring the application of NLP to reduce medication errors, this AHRQ-funded review describes challenges associated with using NLP to extract information from clinical sources and highlights how engaging pharmacists in developing NLP systems can improve medication safety.
Zhou L, Blackley SV, Kowalski L, et al. JAMA Netw Open. 2018;1:e180530.
… , documentation is widely perceived to be inefficient and a significant driver of physician burnout . Speech … emergency medicine and radiology notes . A  WebM&M commentary  discussed an adverse event that occurred due to a transcription error in a radiology study report. … Zhou L; Blackley SV; Kowalski L; Doan R; Acker WW; Landman …
Goss FR, Zhou L, Weiner SG. Int J Med Inform. 2016;93.
The adoption of new technology in health care often produces unintended consequences, which can be mitigated by applying human factors engineering principles to user interface design. Due to efficiency gains, the use of speech recognition technology among physicians has grown in recent years. Investigators analyzed notes dictated by emergency medicine physicians and found that 71% of the notes contained errors. Given that 15% of the errors were considered critical, the authors suggest speech recognition technology may create miscommunication that could adversely affect patient care.
Topaz M, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2016;23:601-608.
Alert fatigue is recognized as a barrier to patient safety and may particularly increase risks associated with medication prescribing. This study examined the frequency of manual overrides of alerts for medication allergies over a 10-year period. Clinicians were required to provide a reason for overriding the allergy alert. As with earlier studies, the rate of overrides was very high. Researchers determined that the alerts were irrelevant in more than half the cases. Providers also were more likely to override repeated alerts compared with new alerts. These results highlight the overuse of alerts in health care settings and the need to improve their use to effectively support patient safety.
Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-8.
Overdose of the commonly used over-the-counter analgesic acetaminophen can lead to serious liver toxicity. In the outpatient setting, unintentional acetaminophen overdose has been linked to poor health literacy and lack of standardization of medication instructions. This study of acetaminophen prescribing among inpatients at two academic medical centers found that 6.6% of patients received more than the recommended daily dose of the drug, with elderly patients and patients with preexisting liver disease being most vulnerable to dosing errors. The authors identified several other risk factors for errors, including use of scheduled around-the-clock dosing (instead of as-needed dosing) and prescribing of more than one acetaminophen-containing product. Notably, these errors occurred at hospitals with computerized provider order entry systems, and the authors note that existing clinical decision support systems lack the capability to warn clinicians when the maximum daily dose of a medication is about to be exceeded.