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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 - 12 of 12 Results
Ni Y, Lingren T, Huth H, et al. JMIR Med Inform. 2020;8:e19774.
Interoperability of smart pumps and electronic health record (EHR) systems can improve clinical data accuracy. This study evaluated the utility of harmonizing EHR data and smart pump records (SPRs) in detecting medication administration errors in one neonatal intensive care unit (NICU). The authors found that compared with medication administration records, dosing discrepancies were more commonly detectable using integrated SPRs, which suggests that this approach may be a more reliable data source for medication error detection.
Melton KR, Timmons K, Walsh KE, et al. BMC Medical Inform Decis Mak. 2019;19:213.
Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.
Ni Y, Lingren T, Hall ES, et al. J Am Med Inform Assoc. 2018;25:555-563.
Preventing medication administration errors remains challenging. In this prospective study, investigators found that implementation of an automated system for detecting medication administration errors in a single neonatal intensive care unit improved identification of errors.
Gipson DS, Kirkendall E, Gumbs-Petty B, et al. Pediatrics. 2017;139.
Taxonomies help to consistently organize data and evidence for use in research. This commentary describes the development of a terminology specific to adverse events in children for use in various settings. The authors note that the tool will be continuously updated and is expected to mature over time.
Stockwell DC, Bisarya H, Classen D, et al. J Patient Saf. 2016;12:180-189.
Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.
Stockwell DC, Bisarya H, Classen D, et al. Pediatrics. 2015;135:1036-42.
Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.
Kirkendall E, Spooner A, Logan JR. J Am Med Inform Assoc. 2014;21:e43-9.
Comparing the accuracy of electronic dosing rules provided by a commercial vendor with traditional clinical dosing rules in pediatrics, this stimulation study found that the electronic rules were accurate only 55% of the time. This finding highlights the possible unintended consequences of health information technology (IT) on patient safety and underscores the specific challenge of pediatric medication prescribing. A recent AHRQ WebM&M commentary examines the complex issues around medication dosing for pediatric patients.
Stockwell DC, Kirkendall E, Muething S, et al. J Patient Saf. 2013;9:203-10.
This study investigated the use of an automated adverse event detection system at two academic children's hospitals. Similar to prior studies, the automated triggers detected many more events than voluntary incident reporting systems.
Kirkendall E, Kloppenborg E, Papp J, et al. Pediatrics. 2012;130:e1206-14.
The Institute for Healthcare Improvement's (IHI) Global Trigger Tool is a well-established sampling method for measuring adverse events in adult patients. Previously, a modified pediatric-focused tool aimed at identifying medication-related errors was developed; however, the full IHI trigger tool has never been formally evaluated in a pediatric setting. In this retrospective chart review study, the Global Trigger Tool identified a higher rate of harm (2 to 3 times) than that seen in previous pediatric research. Dr. Paul Sharek discusses trigger tools and other approaches for measuring adverse event rates in an AHRQ WebM&M perspective.