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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 - 18 of 18 Results
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28:2654-2660.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.
Patient Safety Innovation September 29, 2021
… JMIR Med Inform … Medication administration errors are a common source of patient harm. Considerable effort has been … and ICU). Findings indicate that execution of MED.Safe at a second site was feasible and effective in detecting … Studies … Ni Y, Lingren T, Hall ES, Leonard M, Melton K, Kirkendall ES. Designing and evaluating an automated system …
Marshall TL, Ipsaro AJ, Le M, et al. Pediatrics. 2021;147:e20192400.
Missed or delayed diagnoses can lead to treatment delays and worse outcomes. This article describes a quality improvement intervention intended to improve physician reporting of suspected diagnostic errors affecting pediatric patients. Intervention components included a standardized reporting process and a systematic feedback and evaluation process, as well as efforts to increase physician engagement, awareness, and psychological safety.  
Ni Y, Lingren T, Huth H, et al. JMIR Med Inform. 2020;8:e19774.
Interoperability of smart pumps and electronic health record (EHR) systems can improve clinical data accuracy. This study evaluated the utility of harmonizing EHR data and smart pump records (SPRs) in detecting medication administration errors in one neonatal intensive care unit (NICU). The authors found that compared with medication administration records, dosing discrepancies were more commonly detectable using integrated SPRs, which suggests that this approach may be a more reliable data source for medication error detection.
Hagedorn PA, Singh A, Luo B, et al. J Hosp Med. 2020;15:378-380.
Secure text messaging has emerged as one method to improve communication between providers and nurses. This paper discusses concerns over alarm fatigue, communication errors and omitting critical verbal communication and provides proposed solutions to support appropriate and effective use of text messaging in a healthcare setting. 
Hagedorn PA, Kirkendall E, Kouril M, et al. JAMA Pediatr. 2017;171:392-393.
… errors in pediatric patients . Investigators used a trigger tool to detect weight-entry errors in the … identify pediatric patients at risk for dosing errors. … Hagedorn PA, Kirkendall ES, Kouril M, et al. Assessing Frequency and Risk …
Stockwell DC, Bisarya H, Classen D, et al. J Patient Saf. 2016;12:180-189.
… remains challenging, but assessing the potential for a given safety problem to cause harm is even more … around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger … of discussion and evidence review, investigators produced a list of 51 triggers , which they plan to pilot test. The …
Kirkendall ES, Kouril M, Dexheimer JW, et al. J Am Med Info Assoc. 2016;24:295-302.
… fatigue  may occur. In this study, investigators used a trigger tool approach and reviewed all antibiotic … medication alerts and thereby reduce medication errors. A recent WebM&M commentary described a medication overdose related to alert fatigue. …
Stockwell DC, Bisarya H, Classen D, et al. Pediatrics. 2015;135:1036-42.
Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.
Stockwell DC, Kirkendall E, Muething S, et al. J Patient Saf. 2013;9:203-10.
This study investigated the use of an automated adverse event detection system at two academic children's hospitals. Similar to prior studies, the automated triggers detected many more events than voluntary incident reporting systems.
Kirkendall E, Kloppenborg E, Papp J, et al. Pediatrics. 2012;130:e1206-14.
… for Healthcare Improvement's (IHI) Global Trigger Tool is a well-established sampling method for measuring adverse events in adult patients. Previously, a modified pediatric-focused tool aimed at identifying … full IHI trigger tool has never been formally evaluated in a pediatric setting. In this retrospective chart review …