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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 - 18 of 18 Results
Prgomet M, Li L, Niazkhani Z, et al. J Am Med Inform Assoc. 2017;24:413-422.
While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.
Horsky J, Aarts J, Verheul L, et al. Int J Med Inform. 2017;97:1-11.
Prior research has shown that providers frequently override drug interaction alerts, sometimes as a result of alert fatigue. In this study, researchers observed providers as they completed medication orders, addressing both high- and low-severity drug interaction alerts using five distinct electronic health records in two countries. The authors found that providers engaged in complex clinical reasoning prior to declining an alert, balancing various aspects of patient care including safety- and patient-specific factors.
Magrabi F, Aarts J, Nohr C, et al. Int J Med Inform. 2013;82:e139-48.
Implementation of health information technology (IT) has presented several unanticipated patient safety issues, particularly related to computerized provider order entry. Health IT vendors generally have a "hold harmless" clause that removes their liability for patient harm due to health IT failures. This review explores patient safety initiatives for health IT systems across six countries, including the United States. Significant gaps in health IT safety initiatives were identified, including inadequate regulatory oversight in the US for these medical devices. The authors conclude that greater standardization and oversight is required to ensure safety for all types of health IT systems. An AHRQ WebM&M interview with Dr. David Bates discusses the benefits and potential risks of health IT.
van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-8.
Alerts within a computerized provider order entry system were not able to prevent medication errors resulting from drug–drug interactions. The authors hypothesize that the inadequacy of the alerts themselves was responsible for this failure, with problems including an excessive number of false-positive alerts and unclear instructions for preventing drug interactions.
van der Sijs H, Aarts J, van Gelder T, et al. J Am Med Inform Assoc. 2008;15:439-48.
This study examined nearly 2000 drug–drug interaction (DDI) alerts that were overridden by providers and noted differential triggers based on clinician knowledge or specialty. The authors conclude that simply turning off DDI alerts is limited by these differential triggers and inconsistent drug monitoring, which may raise safety concerns that are prevented by the alerts themselves.
Ash JS, Berg M, Coiera E. J Am Med Inform Assoc. 2004;11:104-12.
The authors draw from their aggregated experience in qualitative assessment of clinical information systems in the United States, Europe, and Australia to propose a framework for understanding unexpected adverse consequences of patient care information systems (PCIS) on clinical work. The adverse effects are broadly divided into errors in the process of entering and retrieving information in or from the system and errors in the communication and coordination processes that the PCIS is intended to support. The authors highlight the mismatch between the linear, rigid design of software and the cognitive, social, and organizational realities of health care delivery. The article was among the first and most influential in a wave of papers highlighting potential drawbacks in clinical information technology, and tempering the impression of computerized provider order entry systems as a universal good.