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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 111 Results
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.
Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Kern-Goldberger AR, Nicholls EM, Plastino N, et al. Am J Obstet Gynecol MFM. 2023:100893.
Many labor and delivery wards have implemented continuous fetal and maternal monitoring to improve patient safety, but this continuous monitoring may also have unintended consequences, such as alarm fatigue. This labor and delivery ward sought to decrease the overuse of monitoring, and related false or missed alarms, on low-risk obstetrical patients. Through the development and implementation of a vital sign guideline assessment, the rate of alarms was decreased with no increase in maternal complications.
Feather C, Appelbaum N, Darzi A, et al. BMJ Qual Saf. 2023;32:357–368.
Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient orders and improve antimicrobial and opioid stewardship. This review identified 21 studies describing interventions to encourage prescribers to include indications for medications. In addition to patient safety benefits, several risks and drawbacks were uncovered, such as potential loss of patient privacy or alert fatigue.
Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

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.
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.

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.
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. 

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.
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.
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.
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.
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.
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.
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.
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).