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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 - 14 of 14 Results
Gabriel MH, Powers C, Encinosa W, et al. Med Care. 2017;55:456-462.
Hypoglycemia is a common and severe adverse drug event among patients with diabetes. This retrospective study of claims data found that Medicare patients with diabetes were less likely to be hospitalized or seen in the emergency department for hypoglycemia if their medications were prescribed electronically, compared to those receiving fewer or no electronic prescriptions. These findings add to the literature demonstrating the benefits of electronic prescribing.
Furukawa MF, Spector WD, Limcangco R, et al. J Am Med Inform Assoc. 2017;24:729-736.
Electronic health records have both safety benefits and unintended consequences. This analysis used data from the 2010–2013 Medicare Patient Safety Monitoring System to compare the incidence of in-hospital adverse events among hospitals that did and did not meet meaningful use requirements for health information technology (IT), according to the Healthcare Information Management Systems Society Analytics Database. Investigators found that hospitals that met meaningful use criteria also reported fewer adverse events. Although the study design does not establish a causal relationship between implementation of health IT and the decline in adverse events, the authors argue that these advances in health IT contributed to this patient safety improvement.
Furukawa MF, Eldridge N, Wang Y, et al. J Patient Saf. 2020;16:137-142.
Electronic health record (EHR) adoption was widely spurred by an assumption that it would improve patient safety. Although research suggests that EHRs have had an overall positive effect, unexpected consequences have occurred along the way and many problems remain. This retrospective study compared adverse events among patients in hospitals with fully electronic EHRs to those without such EHRs in place. After controlling for patient and hospital characteristics, patients exposed to a fully electronic EHR had 17% to 30% lower odds of having an adverse event. A recent PSNet interview with Dr. Robert Wachter discussed the role of health information technology in patient safety.
Powers C, Gabriel MH, Encinosa W, et al. J Am Med Inform Assoc. 2015;22:1094-8.
This analysis of Medicare data found that outpatient practices using electronic prescribing had fewer adverse drug events among their panel of patients with diabetes compared to practices not consistently using electronic prescribing. Although promising, this study does not address the many differences between practices that use electronic prescribing versus those that do not and the patients that select these disparate health care systems.
King J, Patel V, Jamoom EW, et al. Health Serv Res. 2014;49:392-404.
This survey of more than 1700 physicians in ambulatory practice found generally positive perceptions of electronic health records (EHRs), with approximately 80% reporting that EHRs enhanced the overall quality of care for patients. Respondents also noted safety benefits, with two-thirds reporting that the EHR alerted them to a potential medication error.
Hsiao C-J, Jha AK, King J, et al. Health Aff (Millwood). 2013;32:1470-7.
This survey found that by 2012, 72% of ambulatory-based physicians in the United States had implemented some form of electronic health record and 40% were using computerized provider order entry. These figures represent a substantial increase over the past several years.
DesRoches CM, Charles D, Furukawa MF, et al. Health Aff (Millwood). 2013;32:1478-85.
Despite considerable federal financial incentives intended to promote electronic health record (EHR) use, as of 2012 only 42.2% of hospitals in the United States had implemented a system that met federal "meaningful use" criteria (which include use of computerized provider order entry with decision support). Rural and nonteaching hospitals were less likely to have implemented an EHR compared with larger urban hospitals.
Spector WD, Mutter R, Owens P, et al. Med Care. 2012;50:863-9.
Nearly 1 in 7 elderly patients hospitalized due to traumatic injuries was readmitted within 30 days of discharge, according to this analysis of more than 200,000 admissions. As in prior studies in other patient populations, the risk of readmission was increased for patients who experienced a Patient Safety Indicator event.
Friedman B, Encinosa W, Jiang J, et al. Med Care. 2009;47:583-90.
Preventable medical errors have been linked to longer hospitalizations, excess costs, and increased mortality. This study explored the longer term effects of patient safety incidents by exploring whether adverse events, as measured by AHRQ's Patient Safety Indicators, were linked to an increased risk of hospital readmission. Patients who suffered a pulmonary embolism or an accidental puncture or laceration during hospitalization were significantly more likely to be readmitted within 1 month, and a broad array of adverse events were linked to a 3-month increased readmission risk. Two cases of preventable readmissions are discussed in this AHRQ WebM&M commentary.
Encinosa W, Hellinger FJ. Health Serv Res. 2008;43:2067-85.
The financial costs associated with medical errors have gained increasing attention, due to the Centers for Medicare and Medicaid Services policy of nonpayment for certain preventable adverse events. This study sought to estimate costs associated with adverse events (measured by the Agency for Healthcare Research and Quality's Patient Safety Indicators) in surgical patients. Importantly, by measuring costs for a 90-day period after surgery, the authors were able to estimate the postdischarge financial impact of adverse events. Up to 20% of costs were incurred after hospital discharge, and the investigators found significant impact of adverse events on mortality and hospital readmissions. The implications of this study and prior research in this area help formulate a business case for safety.
Furukawa MF, Raghu TS, Spaulding TJ, et al. Health Aff (Millwood). 2008;27:865-75.
Continued adoption of health information technology (HIT) systems is driven by efforts to improve safety and quality, but unintended consequences of these systems have been reported. This study used a national survey database to analyze the extent of HIT adoption specifically for medication safety. Investigators discovered wide variations across technologies, hospital characteristics, and geographic locations, with an average hospital adopting 2.24 out of 8 HIT applications. The authors were most struck by the association seen between HIT adoption and states' patient safety initiatives, suggesting the impact of state regulation and patient safety centers in facilitating adoption. They also advocate for thoughtful policy and governmental incentives to further foster HIT adoption moving forward.
Briesacher B, Limcangco R, Simoni-Wastila L, et al. J Am Geriatr Soc. 2005;53:991-6.
This study explored the effect of a Centers for Medicare and Medicaid Services policy on inappropriate medication use in nursing homes. The authors conclude that the effect of nationally mandated drug reviews is unclear and suggest that more effective safeguards are needed.
Encinosa W, Bernard DM. Inquiry. 2005;42:60-72.
This AHRQ–funded study examined the relationship between hospital profit margins and the rate of patient safety events. Using data from 176 acute care hospitals in Florida, investigators categorized hospitals into four tiers based on their reported profit margins and compared event rates from more than one million surgical hospitalizations. Findings illustrated an inverse relationship, with the highest event rate occurring in hospitals with the lowest margins. The authors suggest that growing financial constraints may limit a hospital’s investment in patient safety, leading to greater numbers of adverse events.