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.
Emani S, Rodriguez JA, Bates DW. J Am Med Inform Assoc. 2023;30:995-999.
Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.
Schnock KO, Garber A, Fraser H, et al. Jt Comm J Qual Patient Saf. 2023;49:89-97.
Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
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.
Syrowatka A, Song W, Amato MG, et al. Lancet Digit Health. 2022;4:e137-e148.
… promising areas where AI could be used to predict (e.g., therapeutic response) or detect (e.g., medication prescribing errors) patient harm. … Syrowatka A, Song W, Amato MG, et al. Key use cases for artificial intelligence …
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.