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 162 Results

Pharmacy e-prescription dispensing before and after CancelRx implementation.

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Pitts SI, Olson S, Yanek LR, et al. JAMA Intern Med. 2023;Epub Sep 5.

Previous research has found that CancelRx can improve communication between electronic health record (EHR) systems and pharmacy dispensing systems and increase successful medication discontinuation. This interrupted time series analysis assessed the impact of CancelRx implementation on successful discontinuation of medications e-prescribed in ambulatory healthcare settings. After CancelRx implementation, the proportion of e-prescriptions sold after discontinuation in the EHR decreased from 8.0% to 1.4%.

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

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Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

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Allen A. KFF Health News. June 21, 2023.

A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.

A novel approach for assessing bias during team-based clinical decision-making.

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Pool N, Hebdon M, de Groot E, et al. Front in Public Health. 2023;11:1014773.

Clinical decision-making can be influenced by both individual and team factors. This article describes the de Groot Critically Reflective Diagnoses Protocol (DCRDP), which can be used to evaluate how group dynamics and interactions can influence collective clinical decision-making. Transcripts of recorded decision-making meetings can be coded based on six DCRPD criteria (challenging groupthink, critical opinion-sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation), which identify teams that are interactive, reflective, higher functioning, and more equitable.

Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.

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Allen G, Setzer J, Jones R, et al. Jt Comm J Qual Patient Saf. 2023;49:247-254.

Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.

Events that inspired change: the importance of sharing what happened to stop it from happening again.

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Myers E, Allen C. Patient Saf. 2023;5:62-63.

Event reporting is core to identifying system-level problems that could harm patients. This article shares several instances of learning from event reports submitted in the state of Pennsylvania to illustrate the value of reporting in patient safety.

Maternal Safety and Perinatal Mental Health

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Perspective on Safety March 29, 2023

This piece focuses on perinatal mental health and efforts to improve maternal safety.

In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health

Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery

Patient and health care professional perspectives on stigma in integrated behavioral health: barriers and recommendations.

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Phelan SM, Salinas M, Pankey T, et al. Ann Fam Med. 2023;21:s56-s60.

Stigma can prevent patients from seeking necessary mental health care. In this study, researchers conducted qualitative interviews with patients and health care providers to assess mental health stigma and barriers to use of integrated behavioral health (IBH) in primary care settings. Participants identified the importance of normalizing discussions about mental health care and patient-centered communication.

Improving clinician well-being and patient safety through human-centered design.

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Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;329:1149-1150.

The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

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Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.

Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.

Accuracy in patient understanding of common medical phrases.

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Gotlieb R, Praska C, Hendrickson MA, et al. JAMA Netw Open. 2022;5:e2242972.

Ensuring patients understand their diagnosis and care plan is important to achieving optimal outcomes. However, patients routinely report not understanding what their provider has told them. In this study, adults were asked for their understanding of jargon clinicians regularly use (“negative” test results, NPO) and a corresponding statement without jargon (“you do not have an infection”, “nothing by mouth”). Some jargon was better understood (“negative”) than other jargon (“occult infection”). Participant demographics were not significantly associated with understanding jargon.

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

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Pitts S, Yang Y, Thomas BA, et al. J Am Med Inform Assoc. 2022;29:2101-2104.

The CancelRx tool is designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. However, interoperability issues can limit the tool’s usefulness and result in inadvertent dispensing of discontinued medications. This evaluation of discontinued medications at one health systems over a one-month period found that only one-third to one-half of discontinued medications were e-prescribed using the same EHR system and would result in a CancelRx message to the pharmacy; the remainder of discontinued medications were patient-reported or reconciled from outside sources.

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

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Sachs JD, Karim SSA, Aknin L, et al. Lancet. 2022;400:1224-1280.

COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

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Pitts S, Yang Y, Woodroof T, et al. J Patient Saf. 2022;18:e934-e937.

CancelRx is a health information tool designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. This study found that CancelRx implementation eliminated the sale of electronically prescribed medications after discontinuation in the EHR, compared to prior to implementation. Researchers found that CancelRx did result in the unintentional cancellation of some prescriptions and they discuss the importance of situational awareness among providers and pharmacy staff to mitigate this issue.

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions.

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Lester CA, Flynn AJ, Marshall VD, et al. J Am Med Inform Assoc. 2022;29:1471-1479.

Although e-prescribing has improved the safety of medication ordering, preventable errors persist. This study analyzed product descriptions (ingredient, strength, dose form) of more than 10 million e-prescriptions. Results show a wide variety in the way drug product descriptions are entered into e-prescription programs (e.g., 707 variants for “oral tablet” such as tablet, tab, po tab). Poor standardization of terminology in e-prescription programs can lead to incorrect medication order and patient confusion.

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

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Patel S, Pierce L, Jones M, et al. Jt Comm J Qual Patient Saf. 2022;48:165-172.

… improvement as part of a non-punitive system. … Patel S, Pierce L, Jones M, et al. Using participatory design to engage physicians in …

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

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McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.

Deprescribing is one intervention to reduce the risk of adverse drug events, particularly in older adults and people taking five or more medications. In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital admission were randomly assigned to intervention (personalized reports of deprescribing opportunities) or control. Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or adverse drug withdrawal events.

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

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Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

The impact of health information management professionals on patient safety: a systematic review.

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Kemp T, Butler‐Henderson K, Allen P, et al. Health Info Libr J. 2021;38:248-258.

… for HIM professionals. … Kemp T, Butler-Henderson K, Allen P, et al. The impact of health information management …

From implementation to sustainment: a large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration.

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Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8:100496.

… across the VA system. … Elwy AR, Maguire EM, McCullough M, et al. From implementation to sustainment: a large-scale …

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