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 108 Results

The relationship between job stress and patient safety culture among nurses: a systematic review.

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Zabin LM, Zaitoun RSA, Sweity EM, et al. BMC Nurs. 2023;22:39.

Fostering a culture of safety is an essential component of improving patient safety and health care quality. This systematic review of seven articles identified a negative relationship between job-related stress among nurses and patient safety culture. Studies also reported that factors such as fatigue, workload, burnout, and workplace violence contribute to job-related stress and resulted in decreased patient safety culture.

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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WebM&M Case February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

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Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

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Patient Safety Innovation November 16, 2022

While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to identify and reduce the number of alerts clinicians encounter every day.

Allergic adverse drug events after alert overrides in hospitalized patients.

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Luri M, Gastaminza G, Idoate A, et al. J Patient Saf. 2022;18:630-636.

Clinical decision support systems can alert prescribers to potential interactions between the drug being ordered and other drugs or drug allergies. Earlier studies have shown high rates of overrides of drug allergy alerts. This study analyzed allergic adverse drug events that occurred because of overridden drug allergy alerts (ODAA). Less than 10% of ODAA were inappropriate and resulted in only mild adverse events.

Overriding drug-drug interaction alerts in clinical decision support systems: a scoping review.

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Villa Zapata L, Subbian V, Boyce RD, et al. Stud Health Technol Inform. 2022;290:380-384.

Computerized decision support systems can alert clinicians to drug-drug interactions (DDIs), but the alert fatigue contributes to alert overrides. This scoping review includes 34 studies from the United States and international settings and identified a high prevalence of DDI alert overrides. The authors discuss the need for improved decision support systems to improve DDI alerts and actionable metrics to measure harms associated with alert overrides.

Algorithm that detects sepsis cut deaths by nearly 20 percent.

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Bushwick S. Scientific American. August 1, 2022.

Sepsis identification is challenging, and delays can be deadly. This article discusses how an artificial intelligence program at one hospital over two years contributed to more timely sepsis diagnosis and treatment.

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

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Brown A, Cavell G, Dogra N, et al. Int J Med Inform. 2022;164:104780.

Alert fatigue and subsequent overrides are known contributors to preventable adverse events particularly for high-risk drug-drug interactions. Researchers assessed prescribers’ actions following an alert for new prescriptions of Low Molecular Weight Heparins (LMWHs) to patients currently prescribed Direct Acting Anticoagulants (DOACs). More than half of the alerts were overridden but were appropriate and justified in most cases.

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

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Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;31:716-724.

Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.

The potential for leveraging machine learning to filter medication alerts.

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Liu S, Kawamoto K, Del Fiol G, et al. J Am Med Inform Assoc. 2022;29:891-899.

Alert fatigue contributes to task burden and can threaten patient safety. In this study, researchers at one academic medical center found that machine learning techniques could enable intelligent filtering of medication alerts and reduce alert volume by 54%.

Habit and automaticity in medical alert override: cohort study.

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Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.

Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.

Systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration.

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Bernstein SL, Catchpole K, Kelechi TJ, et al. Jt Comm J Qual Patient Saf. 2022;48:309-318.

Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.

Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey.

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Van De Sijpe G, Quintens C, Walgraeve K, et al. BMC Med Inform Decis Mak. 2022;22:48.

Clinical decision support systems (CDSS) can help identify potential drug-drug interactions (DDI), but they can lead to alert fatigue and threaten patient safety. Based on an analysis of DDI alerts and survey data regarding physician experience using the DDI module in the CDSS, researchers identified barriers (i.e., lack of patient-specific characteristics and DDI-specific screening intervals) that contribute to false-positive alerts and alert fatigue.

Improving the specificity of drug-drug interaction alerts: can it be done?

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Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;79:1086-1095.

Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

Annual Perspective: Topics in Medication Safety

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Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.

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WebM&M Case November 30, 2021

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

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Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28:2654-2660.

Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.

Safety culture as a patient safety practice for alarm fatigue.

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Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326:1207-1208.

Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

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Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.

Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.

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