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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 27 Results
Koppel R, Kuziemsky C, Elkin PL, et al. Stud Health Technol Inform. 2023;304:21-25.
Health information technology (HIT) has improved many aspects of patient safety, but poor design can result in patient harm. This commentary describes how context influences vendor, organization, and user understanding of HIT-related errors and proposes system-level solutions, in particular a focus on user-centered design.
Petersen C, Smith J, Freimuth RR, et al. J Amer Med Inform Assoc. 2020;28:677-684.
… intended to support diagnosis and therapeutic processes of care. This position paper defines adaptive CDS as “systems … for the effective management and monitoring of adaptive CDS are outlined. … Petersen C, Smith J, Freimuth … use of adaptive CDS in the US healthcare system: an AMIA position paper. J Amer Med Inform Assoc. …
Huang C, Koppel R, McGreevey JD, et al. Appl Clin Inform. 2020;11:742-754.
… adverse events can increase during the implementation of a new electronic health record (EHR) system. EHR  transitions … mitigation to avoid patient safety events. … Huang C, Koppel R, McGreevey JD, 3rd, et al. Transitions from one … Clin Inform. 2020;11(5):742-54. Epub Nov 12. doi: 10.1055/s-0040-1718535. …
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Adelman JS, Berger MA, Rai A, et al. J Am Med Inform Assoc. 2017;24:992-995.
Wrong-patient errors can occur during computerized provider order entry, particularly if ordering clinicians have more than one patient record open. Experts have recommended that health systems allow only a single patient record to be open at a time to prevent these errors. This national survey of electronic health record leaders examined whether health systems permit records for multiple patients to be open simultaneously for electronic ordering and documentation. Nearly 200 health systems responded to the survey, and respondents described widely differing practices. Among health systems where clinicians could open multiple patient records at a time, the common justification was to support efficiency. A significant proportion did impose a restriction of working on one patient record at a time, and a smaller group limited clinicians to working with two open patient records only. These results suggest that further study of the optimal number of open patient records is needed to balance safety and efficiency in completing electronic health record work.
Amato MG, Salazar A, Hickman T-TT, et al. J Am Med Inform Assoc. 2017;24:316-322.
Computerized provider order entry (CPOE) systems can effectively prevent many prescribing errors, but their overall safety benefit has not yet been fully realized. More widespread implementation of these systems has revealed new safety concerns. A prior study funded by the US Food and Drug Administration found that many of the safety issues associated with CPOE could be ascribed to poor usability of the systems, the lack of interoperability, and failure to track and learn from concerns identified by users. This follow-up study analyzed more than 1300 CPOE error reports to further classify the types of errors and their impact on patient care. Investigators determined that patients experienced delays in receiving medications due to these errors and were at risk of receiving duplicate medications or incorrect doses of medications. Similar to previous studies, the most common types of CPOE errors included problems with transmitting orders to the correct site of care, incorrect dose, or duplicate orders that were not detected by the system. A WebM&M commentary discussed an error that led to patient harm due to an incorrect default CPOE order.
Berner ES, Ray MN, Panjamapirom A, et al. J Gen Intern Med. 2014;29:1105-12.
… Journal of general internal medicine … J Gen Intern Med … This study … care visits. For the baseline stage, patients received a live follow-up call 3 weeks after their visit. In the … patients were contacted one week after their visit by a live call or an interactive voice response system call, …
Middleton B, Bloomrosen M, Dente MA, et al. J Am Med Inform Assoc. 2013;20:e2-8.
The introduction of health information technology (IT) has resulted in various documented improvements in patient safety and care delivery. However, unintended consequences have also emerged, and the potential for health IT to cause harm is now well recognized. This report includes 10 recommendations for research, policy, industry, and clinician users. These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to improve the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide made recommendations concerning safe implementation of electronic health records. A previous AHRQ WebM&M perspective examines the benefits and challenges of available health IT systems.
Perspective on Safety July 1, 2012
… medication, dose, schedule, and route for the patient's diagnosis, the diagnosis is wrong.( 1,2 ) The challenge in … clinicians. JAMA. 2009;301:1276-1278. [go to PubMed] 14. Goodman KW, Berner ES, Dent MA, et al. Challenges in ethics, safety, best …
This piece examines the promised benefits of health information technology alongside the challenges of implementation and idiosyncrasies of available systems.
Dr. Blumenthal recently returned to Harvard after a 2-year stint as the National Coordinator for Health Information Technology, where he was responsible for implementing the “Meaningful Use” health care IT incentive system in American hospitals and clinics.
Weingart SN, Simchowitz B, Shiman L, et al. Arch Intern Med. 2009;169:1627-1632.
E-prescribing is a growing solution to prevent medication errors, with insurers rewarding the practice and high-risk settings adopting the technology. This study surveyed more than 180 ambulatory providers who use e-prescribing systems and found that respondents believed the system improved the quality of care delivered, prevented errors, and enhanced both patient satisfaction and clinical efficiency. However, less than half the respondents were satisfied with the drug interaction and allergy alerts. The authors advocate for better design of alert systems to prevent alert fatigue yet promote safe prescribing practices. The challenges of implementing effective medication decision support systems are discussed in an AHRQ WebM&M perspective.
Yu FB, Menachemi N, Berner ES, et al. Am J Med Qual. 2009;24:278-86.
… American journal of medical quality : the official journal of the American … provider order entry (CPOE) continues to be hailed as a solution for medication-related errors and quality … CPOE implementation success stories and provide a more generalized link between CPOE and improved outcomes. …
WebM&M Case April 1, 2009
… The Case … A 47-year-old man with advanced AIDS was admitted to an … advanced AIDS, the medical team was concerned about Kaposi's sarcoma and human papillomavirus (HPV) infection, … not force us to prematurely implement inadequate EMRs. … Ross Koppel, PhD … Principal Investigator Study of Hospital …
Isaac T, Weissman JS, Davis RB, et al. Arch Intern Med. 2009;169:305-311.
… Arch. Intern. Med. … Arch Intern Med … The safety benefit of computerized provider order entry systems rests in large … potential drug–drug interactions. However, this study of more than 200,000 alerts generated by a commercial outpatient electronic prescribing system found …
Koppel R, Leonard CE, Localio R, et al. J Am Med Inform Assoc. 2008;15:461-5.
… Journal of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Accurate identification of medication errors poses methodological challenges . This … analyzed orders entered and discontinued within 2 hours as a trigger for inexpensive and rapid real-time …