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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 - 15 of 15 Results
Koppel R, Kuziemsky C, Elkin PL, et al. Stud Health Technol Inform. 2023;304:21-25.
Health information technology (HIT) has improved many aspects of patient safety, but poor design can result in patient harm. This commentary describes how context influences vendor, organization, and user understanding of HIT-related errors and proposes system-level solutions, in particular a focus on user-centered design.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Adelman JS, Berger MA, Rai A, et al. J Am Med Inform Assoc. 2017;24:992-995.
Wrong-patient errors can occur during computerized provider order entry, particularly if ordering clinicians have more than one patient record open. Experts have recommended that health systems allow only a single patient record to be open at a time to prevent these errors. This national survey of electronic health record leaders examined whether health systems permit records for multiple patients to be open simultaneously for electronic ordering and documentation. Nearly 200 health systems responded to the survey, and respondents described widely differing practices. Among health systems where clinicians could open multiple patient records at a time, the common justification was to support efficiency. A significant proportion did impose a restriction of working on one patient record at a time, and a smaller group limited clinicians to working with two open patient records only. These results suggest that further study of the optimal number of open patient records is needed to balance safety and efficiency in completing electronic health record work.
Amato MG, Salazar A, Hickman T-TT, et al. J Am Med Inform Assoc. 2017;24:316-322.
Computerized provider order entry (CPOE) systems can effectively prevent many prescribing errors, but their overall safety benefit has not yet been fully realized. More widespread implementation of these systems has revealed new safety concerns. A prior study funded by the US Food and Drug Administration found that many of the safety issues associated with CPOE could be ascribed to poor usability of the systems, the lack of interoperability, and failure to track and learn from concerns identified by users. This follow-up study analyzed more than 1300 CPOE error reports to further classify the types of errors and their impact on patient care. Investigators determined that patients experienced delays in receiving medications due to these errors and were at risk of receiving duplicate medications or incorrect doses of medications. Similar to previous studies, the most common types of CPOE errors included problems with transmitting orders to the correct site of care, incorrect dose, or duplicate orders that were not detected by the system. A WebM&M commentary discussed an error that led to patient harm due to an incorrect default CPOE order.
Middleton B, Bloomrosen M, Dente MA, et al. J Am Med Inform Assoc. 2013;20:e2-8.
The introduction of health information technology (IT) has resulted in various documented improvements in patient safety and care delivery. However, unintended consequences have also emerged, and the potential for health IT to cause harm is now well recognized. This report includes 10 recommendations for research, policy, industry, and clinician users. These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to improve the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide made recommendations concerning safe implementation of electronic health records. A previous AHRQ WebM&M perspective examines the benefits and challenges of available health IT systems.
Perspective on Safety July 1, 2012
… IT sales because the systems will be truly useful. … Ross Koppel, PhD … Professor, Sociology Department and School of … PubMed] … RossKoppelRoss Koppel … Editor's note: … David Blumenthal, MD, MPP, is Chief Health Information and …
This piece examines the promised benefits of health information technology alongside the challenges of implementation and idiosyncrasies of available systems.
Dr. Blumenthal recently returned to Harvard after a 2-year stint as the National Coordinator for Health Information Technology, where he was responsible for implementing the “Meaningful Use” health care IT incentive system in American hospitals and clinics.
Goodman KW, Berner ES, Dente MA, et al. J Am Med Inform Assoc. 2011;18:77-81.
The American Medical Informatics Association (AMIA) Board developed this position paper to address the extraordinary growth in the adoption of health information technology (HIT). The paper provides wide reaching recommendations about contracts, education and ethics, best practices, marketing, and regulation and oversight of the industry.
WebM&M Case April 1, 2009
… not force us to prematurely implement inadequate EMRs. … Ross Koppel, PhD … Principal Investigator Study of Hospital … TobiasJ TobiasJN Tobias J N TobiasJonahN TobiasJonahNoel … RossKoppelRoss Koppel
Koppel R, Kreda D. JAMA. 2009;301:1276-8.
This commentary examines the current health care information technology (IT) policy that removes liability from health IT vendors when patients are harmed due to health IT failure (for example, if a computerized provider order entry system suggests an incorrect medication dose). It explores the legal basis for the current policy, and suggests a rebalance of responsibility between the vendors and health professionals.
Koppel R, Leonard CE, Localio R, et al. J Am Med Inform Assoc. 2008;15:461-5.
Accurate identification of medication errors poses methodological challenges. This study analyzed orders entered and discontinued within 2 hours as a trigger for inexpensive and rapid real-time evaluation. Investigators discovered that two thirds of orders discontinued within 45 minutes were viewed as inappropriate.
Koppel R, Wetterneck TB, Telles JL, et al. J Am Med Inform Assoc. 2008;15:408-423.
Bar code technology is being rapidly adopted as a mechanism to prevent adverse drug events, but warnings about their unintended consequences have also been reported. This study combined direct observation, interviews, participation in a hospital's FMEA, and examining bar coding override log data to outline the frequency and causes of workarounds caused by the new technology. Investigators discovered 15 workarounds, categorized as omitted steps, steps performed out of sequence, and unauthorized steps, and then identified 31 different causes to these events. Similar to a past study, the authors conclude with recommendations that focus on improving the design, implementation, and workflow integration of bar coding systems to prevent unsafe workarounds.
Koppel R, Metlay JP, Cohen A, et al. JAMA. 2005;293:1197-203.
While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors. This AHRQ-funded study identified 22 situations in which the CPOE system increased the probability of medication errors. According to the study, these situations fell into two categories: information errors generated by fragmentation of data and hospitals' many information systems, and interface problems where the computer's requirements are different than the way clinical work is organized. The study looked at clinicians' experience in using one CPOE system at a major urban teaching hospital.