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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 - 13 of 13 Results
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.
Coleman JJ, Manavi K, Marson EJ, et al. Postgrad Med J. 2020;96:392-398.
Many COVID-19 patients present with respiratory symptoms, but others may present with atypical symptoms (e.g., delirium, smell and taste dysfunction, cardiovascular features). This article summarizes the evidence regarding these atypical presentations and the importance of physicians considering conditions which can “mimic” COVID-19 as part of the differential diagnoses in order to avoid diagnostic uncertainty and diagnostic errors.
Coleman JJ. Expert Opin Drug Saf. 2019;18:69-74.
Medication errors present challenges to patient safety worldwide. Vulnerabilities in the medication-use process are exacerbated by the need to navigate comorbidities in older patients and the general complexity of care. This review examines prescribing concerns and highlights three areas of focus to improve safety: engagement with patients and families as partners in decision making, care coordination, and application of system approaches to support medication safety.
Pontefract SK, Coleman JJ, Vallance HK, et al. PLoS One. 2018;13:e0207450.
The unintended consequences of computerized provider order entry and clinical decision support are well-described. Researchers conducted focus groups with pharmacists and physicians at two acute care hospitals in England and found that both computerized provider order entry and clinical decision support increased different aspects of workload for pharmacists and providers while electronic messaging capability yielded some improvements in interprofessional communication.
Pontefract SK, Hodson J, Slee A, et al. BMJ Qual Saf. 2018;27:725-736.
Although computerized provider order entry (CPOE) reliably reduces medication errors, clinical decision support has more varied impact on safety outcomes. System complexity, insufficient emphasis on human factors engineering, and alert fatigue limit utility of clinical decision support. This study rigorously examined medication error rates before and after implementation of CPOE with clinical decision support at three hospitals in England. In a sample of 2422 patients, the overall error rate decreased 20%. At one hospital, the error rate did not change because an increase in a specific insulin prescribing error counterbalanced all other error reduction. All three hospitals implemented clinical decision support, but the type, nature, and efficacy varied markedly, even between the two systems implementing the same CPOE. A PSNet perspective synthesized lessons for assessing electronic health record safety as a whole.
Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.
Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.
Pontefract SK, Hodson J, Marriott JF, et al. PLoS One. 2016;11:e0160075.
Although electronic health records (EHRs) with computerized provider order entry are known to improve medication safety, experts have raised concerns that EHRs adversely affect interprofessional communication by reducing personal interactions among providers. This study examined unidirectional computerized messages from pharmacists and physicians within the EHR. Investigators found that less than half of messages from pharmacists were acknowledged by the prescribing physicians. Among the messages in which pharmacists requested a specific action, physicians completed the action about one-third of the time. Messages were more likely to be acknowledged and acted upon when pharmacists and physicians had an existing working relationship. The authors suggest that EHRs should be better designed to foster interprofessional collaboration. A PSNet perspective highlighted the role of pharmacists in interprofessional care and safety.
Cresswell K, Bates DW, Williams R, et al. J Am Med Info Asso. 2014;21:e194-e202.
The introduction of computerized provider order entry (CPOE) systems has led to many readily apparent advantages, as well as some serious unintended consequences. This study investigated the effects of introducing a commercial CPOE system with very basic decision support at one hospital and a robust clinical decision support system at another. Both hospitals had used these programs for at least 2 years prior to the study. Negligible overall differences in the consequences were observed between the two systems. Although individuals reported that the computer system seemed to save time for some tasks, most users felt an overall increase in their workloads. Major barriers included the amount of time required to log in and inadequate computer infrastructure in clinical work environments. Clinicians demonstrated an array of workarounds to enhance efficiency, which often undercut patient safety. A previous AHRQ WebM&M interview discussed the unintended consequences of technology.
Dixon-Woods M, Redwood S, Leslie M, et al. Milbank Q. 2013;91:424-54.
Ethnographic observations and semi-structured interview data showed that implementation of an electronic health record with prescribing and decision support led to greater oversight of and improvements in specific safety metrics.
Nwulu U, Nirantharakumar K, Odesanya R, et al. Eur J Clin Pharmacol. 2013;69:255-9.
This retrospective review examined more than 50,000 hospital admissions using two triggers—INR level and use of naloxone (an opioid reversal drug)—to determine whether these criteria improved detection of adverse drug events.
Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.
Hard stop alerts within computerized provider order entry (CPOE) systems are intended to avert serious medication errors by preventing prescribing of contraindicated medications. This study investigated whether data from a CPOE system could be used to identify individual physicians who commit more frequent prescribing errors. However, the study found that trainee physicians who committed errors prompting hard stop alerts were not more likely to commit less serious prescribing errors, nor did they appear to ignore prescribing warnings more frequently. Although objective performance data would help identify doctors who frequently make prescribing errors, this study's results indicate that triggering of CPOE alerts is not a reliable measure.