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.
Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Heyworth L, Paquin AM, Clark J, et al. J Am Med Inform Assoc. 2014;21:e157-62.
Medication errors are a major cause of adverse events after hospital discharge, and as a result, medication reconciliation is a critical part of care transitions programs. This study, conducted at a Veterans Affairs hospital, evaluated a novel method of accomplishing medication reconciliation and identifying potentially dangerous medication errors through patient engagement. Within 72 hours after discharge, patients received a secure e-mail message from a pharmacist asking them to confirm their discharge medication list, indicate whether they had discontinued any prescribed medications, and report any questions. The intervention was well received by patients, and pharmacists detected 108 medication discrepancies in the 51 medication lists sent. Other methods of leveraging information technology to engage patients in medication safety efforts have shown promise, including kiosks for outpatient medication reconciliation and secure messaging to identify adverse drug events after starting new medications.
Simon SR, Keohane CA, Amato MG, et al. BMC Med Inform Decis Mak. 2013;13.
Effective use of computerized provider order entry (CPOE) has been hindered by limited information on how to properly implement these systems. This case study of CPOE at five community hospitals identifies the major resources needed for and factors associated with successful implementation.
Leung AA, Keohane C, Lipsitz S, et al. J Am Med Info Asso. 2013;20:e85-e90.
As more hospitals begin to implement computerized provider order entry (CPOE) systems, rigorously evaluating their real-world performance at preventing medication errors has become crucial. The Leapfrog Group was an early pioneer in calling for wider CPOE implementation, and this study reports on the validation of a tool developed by Leapfrog for assessing the ability of CPOE systems to prevent serious errors. The tool, which uses simulated cases, proved to be effective, as the incidence of errors it detected corresponded closely to the actual error rates of participating hospitals. Prior simulation research has shown that many commercial systems fail to detect even potentially serious errors, and this study provides reassurance that CPOE systems that pass the Leapfrog evaluation are likely to successfully prevent medication errors.
Discrepancies between patients' recorded medication lists and the medications they were actually taking were very common in an ambulatory clinic with a fully integrated electronic health record. The study provides another example that electronic medical records alone are not a foolproof mechanism for preventing errors.
Building on an earlier study, this research letter analyzed closed malpractice claims data from Massachusetts and found that claims were much less common for physicians using electronic health records (EHRs) when compared with physicians not using EHRs.
Leung AA, Keohane C, Amato MG, et al. J Gen Intern Med. 2012;27:801-7.
The increasing use of health information technology, particularly computerized provider order entry (CPOE), has yielded safety benefits but has also been fraught with implementation difficulties. Concern has therefore arisen that the real-world performance of commercial CPOE systems may not match performance seen in research settings or with homegrown systems. This study of CPOE implementation in 5 Massachusetts community hospitals should partly allay those concerns, as preventable adverse drug events declined by nearly one-third over the 5-year study period. However, drug-related near misses increased significantly after CPOE implementation, highlighting the potential for unintended consequences with this technology.
Love JS, Wright A, Simon SR, et al. J Am Med Inform Assoc. 2012;19:610-4.
Electronic health records (EHRs) are increasingly being implemented in both inpatient and outpatient environments, and a growing body of data indicates that EHR implementation is associated with improved quality of care. This survey of more than 500 physicians who regularly used EHRs found that nearly one-third believed that EHRs could actually increase the potential for errors—a belief that has empirical support—although only a very small proportion had actually experienced such an error. Physicians who were concerned about the safety implications of EHRs were also more likely to report dissatisfaction with their practice setting. Implementation of EHRs can significantly disrupt clinicians' work environment, and prior studies have shown that one full year of experience with EHRs is required for providers to view such systems positively. These findings have important implications for organizations planning the implementation process for new EHRs.
Abramson EL, Bates DW, Jenter CA, et al. J Am Med Inform Assoc. 2012;19:644-8.
This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.
Arzy S, Brezis M, Khoury S, et al. J Eval Clin Pract. 2009;15:804-6.
Diagnostic errors frequently occur because of cognitive errors on the part of physicians. This study used case vignettes to vividly illustrate one specific cognitive error, the "framing effect," whereby a clinician places undue emphasis on a single (often extraneous) piece of information. Inclusion of a single misleading detail resulted in experienced clinicians making significantly more diagnostic errors. The process of meta-cognition, or "thinking about thinking," is often used to attempt to overcome this and other biases in clinical decision-making. An AHRQ WebM&M perspective explores issues related to cognitive errors in diagnosis.
Quinn MA, Wilcox A, Orav J, et al. Med Care. 2009;47:924-8.
This study found a positive relationship between being involved in quality improvement activities and physician work–life measures such as practice dissatisfaction, professional isolation, and work–life stress. The authors advocate for greater efforts to engage physicians in quality improvement work, as this may impact the quality of care delivered to their patients.
Virapongse A, Bates DW, Shi P, et al. Arch Intern Med. 2008;168:2362-7.
This study discovered that physicians using electronic health records (EHRs) appear less likely to have paid malpractice claims, though as the authors point out, finding the nature and significance of this relationship requires further investigation.
Lafata JE, Gunter MJ, Hsu J, et al. Med Care. 2007;45:966-72.
This randomized study found that academic detailing yielded modest impact on appropriate monitoring of patients started on selected high-risk medications. A past study also demonstrated limited success with academic detailing as a sole intervention to promote medication safety.
Simon SR, Smith DH, Feldstein AC, et al. J Am Geriatr Soc. 2006;54:963-8.
This study demonstrated that replacing drug-specific alerts with age-specific ones sustained (but did not enhance) previously noted decreases in inappropriate prescribing with drug-specific alerts alone. Investigators conducted a cluster-randomized trial of seven practices that received age-specific alerts in addition to academic detailing with eight practices that received only the alerts. The academic detailing process involved an interactive educational program to assist with alternative and evidence-based medication choices. Findings suggested that clinical decision support can be effective using alert systems, but improvements in tools such as academic detailing are needed, as the process had no benefit in this study. Shifting to age-specific alerts did decrease the alert burden overall to providers. A past review discussed the issue of inappropriate prescribing in the elderly while other studies evaluated its prevalence in outpatient settings and elderly veterans.
Feldstein AC, Smith DH, Perrin N, et al. Arch Intern Med. 2006;166:1009-15.
The authors evaluated the effectiveness of computerized alerts in reducing co-prescribing of warfarin and interacting medications. They found that the alerts had a modest impact on minimizing this potentially dangerous behavior.
Smith DH, Perrin N, Feldstein AC, et al. Arch Intern Med. 2006;166:1098-104.
This AHRQ–funded study discovered that the use of alerts within an electronic medical record system can reduce the number of unsafe medications prescribed in elderly outpatients. Investigators evaluated the impact of a clinical decision support system (CDSS) at the point of computerized provider order entry (CPOE), targeting two classes of contraindicated medications (long-acting benzodiazepines and tertiary amine tricyclic antidepressants). The authors discuss the rapid, significant, and persistent reductions in medication prescribing of these high-risk medications, suggesting the effectiveness of an alert system to curtail inappropriate prescribing. This study is a first to evaluate a computerized alert system in a large population-based primary care setting, although a past systematic review evaluated the effects of CDSS on practitioner performance and patient outcomes.
Mazor KM, Simon SR, Gurwitz JH. Arch Intern Med. 2004;164:1690-7.
While professional guidelines, recommendations from credentialing and patient safety organizations, and experts on medical errors advocate for disclosure of medical errors, this study conducted a review to understand what practices are recommended in the literature. The authors found empirical support that the act of disclosure to patients doesn't consistently occur, that patients and the general public favor disclosure, and that physicians do in fact support the practice. However, little practical guidance exists as to the nuts and bolts of who, what, when, and how to disclose, which the authors point out must become a focus of future efforts. Another related past study discussed patients' and physicians' attitudes regarding the disclosure of medical errors.