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.
Usability concerns continue to affect the safe use of electronic health information systems. This commentary describes the role of vendors in improving usability, how regular testing can ensure safety, and the impact of organizational culture on the safe use of information technology over time.
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.
Taft T, Rudd EA, Thraen I, et al. J Am Med Inform Assoc. 2023;30:809-818.
Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.
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.
Apathy NC, Howe JL, Krevat S, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.
Bocknek L, Kim T, Spaar P, et al. Patient Safety. 2022;4:39-47.
Duplicate medication orders, defined as orders for two or more identical medications or same therapeutic class, can result in serious complications if they reach the patient. This study examined the error type (same medication, therapeutic class, or order), when they were recognized, and factors contributing to the error. Importantly, of duplicate orders in the same therapeutic class, the three most common medications were anti-coagulants, a high-risk medication.
Despite widespread implementation of computerized provider order entry (CPOE) for medication ordering, some orders may be submitted wholly or in part using the free-text field. This study analyzed CPOE orders that included medication information in the free text field. High-risk medications (e.g., insulin, heparin) were frequently mentioned and the most common expected action was to discontinue. Despite using the same CPOE software, there were wide variations between the six included hospitals in the rates of orders in free text and the types of medications mentioned.
Poor usability of electronic health record (EHR)-based computerized provider order entry (CPOE) can lead to adverse events. Using a newly developed self-administered assessment tool, researchers identified several EHR usability and safety issues across medication, laboratory, and radiology CPOE functions.
Sheehan JG, Howe JL, Fong A, et al. J Patient Saf. 2022;18:565-569.
Patient safety event reporting systems are a core component of patient safety and quality improvement. In this study, researchers identified seven publicly available patient safety databases that can be used to identify patient safety risks and opportunities for improvement.
Iqbal AR, Parau CA, Kazi S, et al. Jt Comm J Qual Patient Saf. 2021;47:793-801.
The electronic medication administration record (eMAR) is one technologic strategy to improve medication safety. In this study, usability issues related to eMAR contributed to 473 patient safety event reports. Eight usability challenge categories were identified (e.g. alerts and interoperability). Among these usability challenges, special attention should be paid to workflow and display/visual clutter.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Info Assoc. 2020;27:924-928.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.
Benda NC, Wesley DB, Nare M, et al. J Patient Saf. 2022;18:e1-e9.
To determine whether language barriers contribute to patient safety events, the authors analyzed near-miss and adverse event reports occurring in patients with a preferred language other than English. Of 1,553 included reports, 13% were likely or plausibly related to a patient’s language barrier. The most common strategy for preventing future events cited in these reports involved use of interpreter services.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use.