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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 - 7 of 7 Results
Pilosof NP, Barrett M, Oborn E, et al. Int J Environ Res Public Health. 2021;18:8391.
The COVID-19 pandemic has led to dramatic changes in healthcare delivery. Based on semi-structured interviews and direct observations, researchers evaluated the impact of a new model of remote inpatient care using telemedicine technologies in response to the pandemic. Intensive care and internal medicine units were divided into contaminated and clean zones and an integrated control room with audio-visual technologies allowed for remote supervision, communication, and support. The authors conclude that this model can increase flexibility in staffing via remote consultations and allow staff to supervise and monitor more patients without compromising patient and staff safety.
Leviatan I, Oberman B, Zimlichman E, et al. J Am Med Inform Assoc. 2021;28:1074-1080.
Human factors, such as cognitive load, are main contributors to prescribing errors. This study assessed the relationship between medication prescribing errors and a physician’s workload, successive work shifts, and prescribing experience. The researchers reviewed presumed medication errors flagged by a computerized decision support system (CDSS) in acute care settings (excluding intensive care units) and found that longer hours and less experience in prescribing specific medications increased the risk of prescribing errors.
Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173:2039-2046.
Health care–associated infections (HAIs) remain a major contributor to preventable morbidity and mortality in hospitalized patients, despite some progress in combating certain infections. This economic analysis combined a systematic review of estimates of costs attributable to HAIs with HAI incidence data to project hospitals' total financial burden caused by these infections in adult inpatients. The authors conclude that the 5 most common HAIs result in an annual cost to the health care system of nearly $10 billion. Since the majority of HAIs are considered preventable, this finding implies that considerable savings could be achieved through more rigorous HAI prevention efforts. Although the study is limited by the heterogeneous methods of determining costs used in the original studies, other studies have shown a relatively strong business case for hospitals to invest in efforts to prevent HAIs.
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.
Zimlichman E, Keohane C, Franz C, et al. Jt Comm J Qual Patient Saf. 2013;39:312-318.
The uptake of computerized provider order entry (CPOE) in community hospitals has been slow due to difficulties associated with implementation and uncertainty about its real-world performance. One recent study demonstrated that commercial CPOE systems can effectively prevent adverse drug events (ADEs) in community hospitals. This follow-up study sought to establish the business case for CPOE through calculating the hospitals' return on investment (ROI)—accounting for the costs saved by preventing ADEs in relation to the cost of buying and implementing the system. Perhaps the study's greatest utility is that it provides data on the actual implementation costs of CPOE in the community setting, but the ROI for hospitals was modest at best and was actually negative at some hospitals. The authors note that the CPOE system in question had minimal decision support capabilities and even a small increase in ADE prevention via decision support would have improved the ROI. Findings from this study demonstrate that economic evaluation of safety strategies is urgently needed.
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.
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.