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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 - 11 of 11 Results
Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.
Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.
Kinlay M, Zheng WY, Burke R, et al. Res Social and Adm Pharm. 2021;17:1546-1552.
Computerized provider order entry (CPOE) systems have been advocated as a strategy to reduce medical errors, but some errors persist. This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related errors change over time. Studies suggest that system-related errors persist with long-term use of CPOE systems, but future research should explore the types of errors that occur, when they occur, and the system factors contributing to the errors.
Mitchell R, Faris M, Lystad R, et al. Appl Ergon. 2020;82:102920.
The ability to use administrative data that already exists in the system to classify patient safety events is an important step in understanding patient safety events. This retrospective cohort study set in Australia used the WHO International Classification for Patient Safety (ICPS) to identify characteristics and risk factors of preventable deaths resulting from medical or surgical complications. The researchers took findings from coroner’s reports and classified those findings based on the ICPS. Based on the coroner's findings, clinical process and procedures, medication/IV fluids, and healthcare-association infections or complications were the most common causes of death.
Gates PJ, Baysari M, Mumford V, et al. Drug Saf. 2019;42:931-939.
Consistent measures and terminology of care-related patient harm are still needed in health care. This commentary reviews inconsistencies in the nomenclature used in studies of harm as well as limitations of existing harm classification tools. The authors propose a tool that provides a process for developing a standard classification score to record medication-related patient harm.
Gates PJ, Meyerson SA, Baysari M, et al. Drug Saf. 2019;42:13-25.
This meta-analysis examined the role of computerized provider order entry (CPOE) in preventing pediatric dosing errors. Combining the results of 9 studies, researchers estimate that about 5% of pediatric inpatient medication orders contain a dosing error, but it is unclear whether CPOE reduces pediatric dosing errors. The authors call for further studies with controlled designs to determine the effectiveness of CPOE on improving pediatric medication dosing.
Gates PJ, Meyerson SA, Baysari M, et al. Pediatrics. 2018;142:e20180805.
Pediatric medication errors remain an important focus of safety initiatives. This systematic review examined the extent of preventable patient harm from medication errors for pediatric inpatients. The 22 included studies reported incidence rates ranging from 0 to 74 preventable adverse drug events per 1000 inpatient days. Across all studies, most errors were minor and did not result in patient harm. Use of health information technology was associated with less harm. Emphasizing the challenges of detecting and reporting errors, a related editorial calls for standardizing descriptions of preventable adverse events and harm in pediatrics. A WebM&M commentary addressed the high potential for weight-based medication errors in pediatrics and provided recommendations to help mitigate this risk.
WebM&M Case October 1, 2013
… cognitive task creating a new opportunity for error. … Melissa Baysari, PhD … Research Fellow Australian Institute of Health … J Am Med Inform Assoc. 2013;20:1159-1167. [go to PubMed] … MelissaBaysariMelissa Baysari
Westbrook JI, Baysari M, Li L, et al. J Am Med Inform Assoc. 2013;20:1159-67.
The Institute of Medicine highlighted the challenges of health information technology implementation in their 2011 report, Health IT and Patient Safety. A growing list of unintended consequences from computerized provider order entry (CPOE) systems has emerged over the last few years. This study describes a robust classification structure for identifying systems-related errors in CPOE programs. Two hospitals with different CPOE systems were examined. Systems-related errors were found to be frequent, comprising 42% of all prescribing errors, although only 2.2% were serious errors. Both CPOE systems in this study prevented many more prescribing errors than they created, supporting the overall benefit of CPOE for patient safety. An AHRQ WebM&M perspective discussed CPOE and medication safety.
Baysari M, Reckmann MH, Li L, et al. J Am Med Inform Assoc. 2012;19:1003-10.
Human factors engineering studies how users interact with technology and attempts to optimize systems to minimize unintended consequences in real-world usage. Computerized provider order entry (CPOE) systems offer considerable safety advantages, but in real-world situations, many CPOE systems have failed to achieve the anticipated results. This Australian study found that many clinicians did not use CPOE system features that were intended to improve efficiency and safety, possibly because doing so would have forced them to change their workflow substantially. This non-standard usage resulted in the generation of many clinically irrelevant alerts, likely contributing to alert fatigue and probably diminishing the overall safety performance of the system. The study highlights the need for usability testing and careful integration of new technology into existing clinician workflows.
Westbrook JI, Reckmann MH, Li L, et al. PLoS Med. 2012;9:e1001164.
Although computerized provider order entry (CPOE) systems are being more widely implemented and appear to reduce medication errors, little data exists on the effectiveness of specific CPOE systems. This study evaluated the implementation of two widely used off-the-shelf CPOE systems (with limited decision support) and found that both resulted in significant reductions in serious medication errors. The article also details types of new errors induced by CPOE systems, which, while common, were generally not clinically significant. As the evidence base around implementation of CPOE systems remains relatively small, studies like this that evaluate the real-world performance of information technology are increasingly important.
Hinchcliff R, Westbrook JI, Greenfield D, et al. Int J Qual Health Care. 2012;24:1-8.
This study analyzed media coverage of medication errors in Australian newspapers and found that most articles simply reported on errors with little discussion of potential solutions or steps patients could take to minimize error risk.