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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 896 Results
Dixit RA, Boxley CL, Samuel S, et al. J Patient Saf. 2023;19:e25-e30.
Electronic health records (EHR) may have unintended negative consequences on patient safety. This review identified 11 articles focused on the relationship between EHR use and diagnostic error. EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation and communication. The majority of issues were a related to providers’ cognitive processing, revealing an important area of research and quality improvement.
Maul J, Straub J. Healthcare (Basel). 2022;10:2440.
Patient misidentification can lead to serious medical errors and patient harm. This article provides an overview of how artificial intelligence (AI) frameworks can be combined with patient vital sign data to prevent patient misidentification. The authors suggest that this system could provide alerts indicating possible misidentification or it could be paired with other indicator systems as part of a multi-factor misidentification system.
Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;Epub Dec 20.
Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.
Erstad BL, Romero AV, Barletta JF. Am J Health Syst Pharm. 2022;Epub Oct 4.
Weight-based dosing is vulnerable to error due to inaccurate estimation of body weight, use of metric vs. non-metric units, or patients being underweight or overweight. This commentary suggests strategies for reducing weight- and size-based dosing errors including reduction in reliance on estimated body weight, standardizing descriptor (e.g., body mass index), limiting options in the electronic health record (EHR), and integrating complex calculations into the EHR.
Apathy NC, Howe JL, Krevat SA, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
Pitts SI, Yang Y, Thomas BA, et al. J Am Med Inform Assoc. 2022;29:2101-2104.
The CancelRx tool is designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. However, interoperability issues can limit the tool’s usefulness and result in inadvertent dispensing of discontinued medications. This evaluation of discontinued medications at one health systems over a one-month period found that only one-third to one-half of discontinued medications were e-prescribed using the same EHR system and would result in a CancelRx message to the pharmacy; the remainder of discontinued medications were patient-reported or reconciled from outside sources.
Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;73:e67-e74.
Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.
Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Skeff KM, Brown-Johnson CG, Asch SM, et al. J Healthc Manag. 2022;67:339-352.
Electronic health records (EHRs) can improve patient safety but can also contribute to physician burnout. This qualitative study involving physicians and medical trainees found that distress most often occurred when physicians were prioritizing systems-based practice (e.g., EHR-required documentation) over other professional activities, such as patient care, communication, and practice-based learning.  
Saini S, Leung V, Si E, et al. BMJ Qual Saf. 2022;31:787-799.
Antimicrobial stewardship is an important element of patient safety. This scoping review explored how antimicrobial indication documentation can impact antibiotic use and clinical outcomes. The authors conclude that this is a growing area of research interest and note that emerging evidence indicates that appropriate antimicrobial indication documentation can improve prescribing and patient outcomes but that larger trials are needed to provide more robust evidence.
Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.
Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;79:2230-2243.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
McCord JL, Lippincott CR, Abreu E, et al. Dimens Crit Care Nurs. 2022;41:347-356.
Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.
Healy M, Richard A, Kidia K. J Gen Intern Med. 2022;37:2533-2540.
The language used in progress notes in the electronic health record (EHR) can influence the attitudes of and treatment given by subsequent clinicians. This review describes words and phrases that are stigmatizing and provides neutral alternatives (e.g., person with substance use disorder instead of addict). Patients in minoritized groups may be especially impacted by stigmatizing language in progress notes.   
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Pitts SI, Yang Y, Woodroof T, et al. J Patient Saf. 2022;18:e934-e937.
CancelRx is a health information tool designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. This study found that CancelRx implementation eliminated the sale of electronically prescribed medications after discontinuation in the EHR, compared to prior to implementation. Researchers found that CancelRx did result in the unintentional cancellation of some prescriptions and they discuss the importance of situational awareness among providers and pharmacy staff to mitigate this issue.