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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 - 20 of 32 Results
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.
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Blanchfield BB, Demehin AA, Cummings CT, et al. Jt Comm J Qual Patient Saf. 2018;44:583-589.
… associated with maintaining an academic medical center's quality and safety infrastructure, including safety … and quality. … Blanchfield BB, Demehin AA, Cummings CT, Ferris TG, Meyer GS. The Cost of Quality: An Academic Health Center's
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.
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.
McTiernan P, Wachter R, Meyer GS, et al. BMJ Qual Saf. 2015;24:162-6.
Past commentaries have explored the tension between balancing no blame and individual accountability for medical errors. This commentary summarizes a debate exploring accountability in patient safety, with one argument describing the need for health care to differentiate individual failures from systems problems and an opposing perspective suggesting that incorporating blame would hinder progress in patient safety.
Nanji KC, Rothschild JM, Boehne JJ, et al. J Am Med Inform Assoc. 2014;21:481-6.
Computerized provider order entry (CPOE) systems have been widely implemented to prevent adverse drug events due to prescribing errors. This direct observation and interview study in an outpatient pharmacy setting describes changes in practice as a result of electronic prescribing. Consistent with prior studies investigating unintended consequences of CPOE, researchers identified new errors associated with electronic prescribing, as well as potential methods to reduce adverse drug events. To improve safety, the authors recommend developing systems to track abandoned prescriptions, offering incentives for pharmacies to utilize electronic prescribing, and enhancing the interface between electronic health record and pharmacy computer systems to decrease manual entry, limit duplicated prescriptions, and expedite clarification requests. A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong patient and deleted it, mistakenly assuming it would cancel the order.
Slight SP, Seger DL, Nanji KC, et al. PLoS One. 2013;8:e85071.
Computerized provider order entry with clinical decision support can be a powerful tool for alerting clinicians to potential prescribing errors. This study investigated how often and why providers overrode drug–drug interaction (DDI) warnings in an outpatient system that had already been extensively modified to show only the most important alerts. Clinicians frequently overrode critical DDI warnings. More than 30% of alert overrides were considered inappropriate and put patients at significant risks for adverse events. In some of the appropriate alert overrides, clinicians indicated that they would "monitor as recommended" for possible DDI effects, but according to a detailed chart review only about one-third actually did so. This study suggests that medication alert overrides will likely remain an important source of patient harm despite significant efforts to reduce alert fatigue.
Nanji KC, Slight SP, Seger DL, et al. J Am Med Inform Assoc. 2014;21:487-91.
Although computerized provider order entry in the outpatient setting was intended to prevent medication errors, the utility of this intervention may have been limited by alert fatigue. This observational study of outpatient clinical decision support found that approximately 53% of alerts in prescriptions were overridden, half of which should have been addressed. This study underscores the importance of improving clinical decision support to reduce inappropriate alerts in outpatient settings. A recent AHRQ WebM&M commentary highlights strategies to prevent alert fatigue.
Cooper JB, Singer SJ, Hayes J, et al. Simul Healthc. 2011;6:231-8.
Seminal studies and a Joint Commission Sentinel Event Alert have highlighted the importance of engaged leadership in promoting a culture of safety. This study discusses an innovative approach for immersing both clinical and non-clinical management in patient safety through team-based problem solving exercises, where groups of managers were required to respond to a simulated safety threat in real time. Participants found the simulated scenarios to be very effective at illustrating sharp end safety issues and promoting the importance of multidisciplinary teamwork in improving patient safety. A related study also found that formal teamwork training for hospital managers positively impacted safety leadership behaviors.
Nanji KC, Rothschild JM, Salzberg C, et al. J Am Med Inform Assoc. 2011;18:767-73.
Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the lack of computerized systems that promote safe prescribing. This retrospective cohort study analyzed nearly 4000 computer-generated prescriptions over a 4-week period and found a 12% error rate; 35% were considered potential adverse drug events. The error rates varied for different computerized systems (ranging from 5% to 38%) with omitted information the most common error type (60%). The findings suggest that implementing e-prescribing solutions requires more than simply adopting a computerized system. Careful attention is required to assure safe processes and functionality.
Shekelle PG, Pronovost P, Wachter R, et al. Ann Intern Med. 2011;154:693-6.
Research on patient safety has dramatically increased in the past decade, but despite this, the progress of improving safety remains slow. Significant controversy exists about how safety interventions should be evaluated, and even apparently successful interventions may not be generalizable to all settings. This AHRQ-sponsored consensus statement by leaders in the safety field defines a framework for rigorous assessment of safety interventions. This framework calls for investigators to use change theory to develop their projects; provide adequate details of the intervention, implementation process, and the context in which the intervention was conducted; and evaluate both the expected outcomes and potential unintended consequences of the intervention. The accompanying editorial (see link below) discusses the challenges of conducting research in complex settings, and takes note of existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.