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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 22 Results
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Holman T, Waldren SE, Beasley JW, et al. J Am Med Inform Assoc. 2018;25:694-701.
In this study, researchers queried family physicians regarding the utility and challenges associated with meaningful use. Respondents' perceptions were highly variable. Some criteria were perceived as beneficial to patient care, but others were considered burdensome.
Tevis SE, Schmocker RK, Wetterneck TB. J Patient Saf. 2020;16:294-298.
Physicians are known to underuse voluntary incident reporting systems in hospitals. After implementing a patient safety orientation for resident physicians and simplifying their reporting system, investigators observed a 230% increase in trainee incident reports in one hospital. A prior WebM&M commentary discussed the value of incident reporting for errors and near misses.
Cox E, Jacobsohn GC, Rajamanickam VP, et al. Pediatrics. 2017;139.
Family-centered rounding is a key patient engagement strategy for hospitalized children. In this cluster-randomized trial that included nearly 300 families, 2 pediatric inpatient services implemented a checklist to promote family-centered rounding and 2 services provided usual care. Through observation of video-recordings, investigators determined that teams who were given a checklist were more likely to ask families if they had questions and to read back provider orders for confirmation. Although families' perceptions of safety climate improved with checklist implementation, overall quality and safety ratings between the checklist and usual care groups were similar. This trial provides evidence that performing certain elements of the checklist, such as read back, can modestly enhance patient and family engagement.
Carayon P, Wetterneck TB, Cartmill R, et al. J Patient Saf. 2021;17:e429-e439.
This human factors study examined how electronic health record (EHR) implementation affected medication safety. Researchers encountered improvements in transcription, dispensing, and administration errors after EHR introduction. Several types of medication prescribing errors, including choosing the wrong drug, duplicate orders, or orders with incorrect information, increased with EHR use. This study adds to the evidence suggesting EHR implementation has mixed effects on medication safety.
Carayon P, Du S, Brown RL, et al. J Healthc Risk Manag. 2017;36:6-15.
Despite the demonstrated success of technology in reducing medication errors, preventable adverse drug events remain a significant source of harm to patients. Researchers analyzed data on medication safety events in 2 ICUs at a medical center and found 1622 preventable adverse drug events among 624 patients. About one third of these events were related to electronic health record use, including duplicate orders.
Carayon P, Wetterneck TB, Cartmill R, et al. BMJ Qual Saf. 2014;23:56-65.
As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.
Hoonakker P, Carayon P, Brown RL, et al. J Am Med Inform Assoc. 2013;20:252-9.
This study used serial surveys over a 1-year period to assess changes in physician and nurse satisfaction with a new computerized provider order entry system. Though nurses expressed considerable dissatisfaction initially, their satisfaction improved over time, whereas physicians were only moderately satisfied with the system both initially and after gaining more experience.
Wetterneck TB, Walker JM, Blosky MA, et al. J Am Med Inform Assoc. 2011;18:774-782.
This study found that after implementation of computerized provider order entry (CPOE) with robust decision support in two adult intensive care units, the rate of duplicate medication orders increased dramatically. Analysis by a physician and a human factors engineer identified several contributing causes. These ranged from limitations of the system itself (orders for electrolyte repletion were often entered immediately before and immediately after physician shift change, as the CPOE system did not reliably display completed orders) to changes in team workflow (prior to CPOE, only one member of the team would write medication orders on rounds, whereas with CPOE multiple team members could enter orders more or less simultaneously). Similar issues have been documented in prior studies of the unintended consequences of CPOE.
Carayon P, Cartmill R, Blosky MA, et al. J Am Med Inform Assoc. 2011;18:812-9.
This study found that ICU nurses were more accepting of electronic health records (EHR) at 12 months after implementation compared to 3, and this acceptance was predicted by EHR usability and computerized provider order entry usefulness.
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.