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.
Langlieb ME, Sharma P, Hocevar M, et al. J Patient Saf. 2023;19:375-378.
Preventable adverse events can lead to serious patient harm and financial burden for individuals and organizations. Building off prior research estimating the incidence of perioperative medication errors, these researchers performed a systematic review to identify and quantify the downstream costs and patient harm due to medication errors. The researchers estimated that the total additional annual cost of care due to perioperative medication errors was $5.33 billion dollars.
Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2023;38:2052-2058.
Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.
Nanji KC, Roberto SA, Morley MG, et al. Anesth Analg. 2018;126:1537-1547.
In 2016, five patients undergoing routine cataract surgery developed irreversible visual loss during the same morning. Researchers in this study use a systems approach to delineate best practices for improving safety of cataract surgery.
… the headaches recurred. A blood test revealed that his C-reactive protein (CRP) was now elevated, suggesting that … have the resources to triage these incoming messages.(J.M. Perkins, D.E. Attarian, written communication, November … and Quality; January 2018. [Available at] 13. Roy CL, Rothschild JM, Dighe AS, et al. An initiative to improve the …
Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Crit Care Med. 2017;45:1481-1488.
These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.
Nanji KC, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2018;25:476-481.
Medication-related clinical decision support is a ubiquitous component of computerized provider order entry (CPOE). Alerts are intended to reduce medication errors and may improve adherence to recommended treatments, but they have yet to improve clinical outcomes. This cross-sectional study examined how often inpatient providers overrode clinical alerts as well as whether those overrides were appropriate. Over 3 years, clinicians overrode nearly 340,000 alerts. While nearly all duplicate drug alert and drug allergy overrides were appropriate, most renal or age contraindication overrides were inappropriate. Although this single institution investigation of a homegrown, older CPOE system may not be generalizable to more common electronic health records, it does illustrate how alert fatigue compromises patient safety. A previous WebM&M commentary discussed the challenges of designing safe CPOE.
Starmer AJ, Schnock KO, Lyons A, et al. BMJ Qual Saf. 2017;26:949-957.
Handoffs increase the risk of adverse events, mainly due to lapses in communication. Implementation of a standardized approach to handoffs may help improve patient safety. This prospective pre–post intervention study examined the impact of a multicomponent handoff intervention consisting of education, verbal handoff mnemonic implementation (I-PASS), and visual aids on nursing handoffs. Researchers used assessment tools to evaluate both the quality and duration of handoffs. Implementation of the intervention was associated with an overall improvement in the handoff process and did not adversely impact nursing workflow. A previous Annual Perspective highlighted safety issues related to handoffs and care transitions.
Schiff G, Nieva HR, Griswold P, et al. Med Care. 2017;55:797-805.
A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.
Schreiber R, Sittig DF, Ash JS, et al. J Am Med Inform Assoc. 2017;24:958-963.
Lack of interoperabilty and user errors are safety concerns associated with the use of electronic health records (EHRs). This case report provides two examples of problems with order cancellations in EHRs due to ineffective interfacing of systems that led to gaps in care. The authors recommend that hospitals test new information technologies to help identify weaknesses and make the ordering process safer.
Woodcock D, Pranaat R, McGrath K, et al. Stud Health Technol Inform. 2017;234:382-388.
The use of scribes, nonclinical staff who aid clinicians by entering information into electronic health records (EHRs), has increased markedly in the past few years. This qualitative study used interviews with clinicians, administrators, and scribes to develop a sociotechnical framework for the role of scribes with relation to the EHR. A prior commentary suggested that scribes represent a workaround that may inhibit the development of more advanced and user-friendly EHRs.
Slight SP, Beeler PE, Seger DL, et al. BMJ Qual Saf. 2016;26.
Clinical decision support systems are intended to improve safety by providing clinicians with information about potential harms—principally harmful drug interactions and allergies—at the point of care. Analyzing more than 150,000 drug allergy warnings in the inpatient and outpatient settings within a single health care system, this study examined how often the warnings were overridden and the appropriateness of prescribers' reasons for doing so. Clinicians overrode 81% of warnings in hospitalized patients and 77% of alerts in outpatients. More than 96% of the overrides were judged appropriate by independent clinical reviewers. These proportions are similar to prior studies. A common appropriate reason for overriding was that the patient had actually tolerated the drug in question, leading the authors to call for improving the accuracy of allergy documentation in electronic medical records. A few classes of drugs accounted for a large proportion of overridden alerts, suggesting that enhancing the accuracy of allergy warnings for these drugs could significantly reduce the overall burden of alerts. Given that alert fatigue is an increasingly recognized patient safety hazard, creating tailored alerts could help clinical decision support systems achieve their potential to improve safety.
Nanji KC, Patel A, Shaikh S, et al. Anesthesiology. 2016;124:25-34.
Medication errors in the hospital have been studied, quantified, and systematically evaluated for potential solutions. A notable exception is the perioperative setting, where medications given by anesthesiologists often bypass standard safety checks. This study is the largest prospective observational study of anesthesia-related medication events available to date. At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed. Approximately 1 in 20 perioperative medication administrations resulted in a medication error or adverse drug event; 80% of these errors were deemed preventable. None of the errors resulted in death, but 2% were considered life-threatening. There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists. The study took place at an academic hospital with substantial local expertise in medication safety, where operating rooms already used a barcode-assisted syringe labeling system. An accompanying editorial suggests that medication error rates may therefore be even higher in other settings and community hospitals.
Cho IS, Slight SP, Nanji KC, et al. Int J Med Inform. 2015;84:630-9.
Prior studies have shown that prescribing clinicians frequently override computerized alerts warning them of potentially harmful drug interactions. This study found that house staff and physicians with fewer patient encounters were more likely to ignore alerts—as were physicians who graduated from one of the top five medical schools in the United States. Understanding why clinicians override warnings is critical to combating alert fatigue.