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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 - 20 of 28 Results
Krevat S, Samuel S, Boxley C, et al. JAMA Netw Open. 2023;6:e238399.
The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.
Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2023;38:2052-2058.
Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.
Dixit RA, Boxley CL, Samuel S, et al. J Patient Saf. 2023;19:e25-e30.
Electronic health records (EHR) may have unintended negative consequences on patient safety. This review identified 11 articles focused on the relationship between EHR use and diagnostic error. EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation and communication. The majority of issues were a related to providers’ cognitive processing, revealing an important area of research and quality improvement.
Perspective on Safety August 1, 2019
This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
Dr. Smith is Chief Faculty Practices Officer for UCSF Health and a family medicine physician. Over the past 3–4 years, the health system has implemented a robust program using medical scribes in the outpatient setting. We spoke with her about her experience implementing this program, including the benefits and some of the potential patient safety ramifications.
Ash JS, Singh H, Wright A, et al. Health Informatics J. 2019:1460458219833109.
This direct observation and interview study examined safety activities associated with electronic health records. The study team identified decision making, organizational learning, and frontline user engagement (including clinical decision support and training) as the three critical areas for safe use of electronic health records.
Artis KA, Bordley J, Mohan V, et al. Crit Care Med. 2019;47:403-409.
Reporting complete patient information during clinical rounds is important for achieving an accurate diagnosis and informing clinical management. Prior research has shown that data is sometimes omitted or inaccurately communicated on rounds. This observational study compared patient data shared by trainees and medical students on ICU rounds to that contained within the electronic health record. Researchers analyzed photocopies of trainee and student notes as well as audio recordings of their oral presentations. For the 157 patient presentations included in the study, they found all contained data omissions and that other team members on rounds supplemented a minimal amount of data missing from student and trainee presentations. The authors recommend additional oversight and education of trainees with regard to data presented on rounds.
Burchiel KJ, Zetterman RK, Ludmerer KM, et al. J Grad Med Educ. 2017;9:692-696.
… … J Grad Med Educ … Resident work hour limits have been a controversial patient safety strategy. Discussing a recent adjustment to the duty hours requirements, this … new standards on both the medical profession and society. A recent PSNet perspective described the 2017 work hour …
Tolley CL, Forde NE, Coffey KL, et al. J Am Med Info Assoc. 2017;25:575-584.
This systematic review of medication errors in pediatrics settings with computerized provider order entry identified key vulnerabilities in electronic prescribing. Lack of drug dosing alerts, inappropriate alerting, dropdown menu option errors, and overarching problems such as the lack of appropriate dosing choices for specific medications contributed to errors across the included studies. The authors call for more advanced decision support to address these concerns.
Wright A, Ai A, Ash JS, et al. J Am Med Inform Assoc. 2018;25:496-506.
Clinical decision support (CDS) includes electronic alerts that can prevent errors. Excessive or erroneous alerts may lead to alert fatigue or other unintended consequences. Researchers used a blend of qualitative methods such as interviews and quantitative data like alert rates to develop a taxonomy of CDS alert errors. The taxonomy includes the origin of the error, which most commonly occurred with introduction of a new decision support rule, and describes the underlying reason for the error, such as problems with new terms, conceptualization, and building the rule as intended. Errors could cause an alert to fail to appear for a relevant situation or could cause an irrelevant or erroneous alert to appear. Most errors came to light through reports from users. The authors recommend classifying CDS alert errors using this taxonomy so that safety efforts will be consistent and actionable.
Schreiber R, Sittig DF, Ash JS, et al. J Am Med Inform Assoc. 2017;24:958-963.
Lack of interoperabilty and user errors are safety concerns associated with the use of electronic health records (EHRs). This case report provides two examples of problems with order cancellations in EHRs due to ineffective interfacing of systems that led to gaps in care. The authors recommend that hospitals test new information technologies to help identify weaknesses and make the ordering process safer.
Woodcock D, Pranaat R, McGrath K, et al. Stud Health Technol Inform. 2017;234:382-388.
… with clinicians, administrators, and scribes to develop a sociotechnical framework for the role of scribes with relation to the EHR. A prior commentary suggested that scribes represent a workaround that may inhibit the development of more …
Artis KA, Dyer E, Mohan V, et al. Crit Care Med. 2017;45:179-186.
Information provided at bedside rounds is critical for clinical decision-making in inpatient settings. This direct observation study found that laboratory data reported at rounds is prone to error, most often omissions. The authors suggest that inaccurately communicated laboratory data is a prevalent and underrecognized patient safety concern.
Kizzier-Carnahan V, Artis KA, Mohan V, et al. J Patient Saf. 2019;15:246-250.
This study found that laboratory values designated as "abnormal" or "panic" in the electronic health record, which are considered passive alerts, are very common for patients in the intensive care unit. The authors suggest that these passive alerts contribute to the pervasive problem of alert fatigue in the intensive care unit.
Stephenson LS, Gorsuch A, Hersh WR, et al. BMC Med Educ. 2014;14:224.
In this educational study, medical residents missed patient safety issues in a simulated review of the electronic health record. Repeated simulations resulted in improved but suboptimal performance. These findings support the widespread concern that problems with electronic health record usability lead to patient safety events.
Nanji KC, Rothschild JM, Boehne JJ, et al. J Am Med Inform Assoc. 2014;21:481-6.
… pharmacy setting describes changes in practice as a result of electronic prescribing. Consistent with prior … prescriptions, and expedite clarification requests. A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong …