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 598 Results

Post-implementation optimization of medication alerts in hospital computerized provider order entry systems: a scoping review.

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Ledger TS, Brooke-Cowden K, Coiera E. J Am Med Inform Assoc. 2023;30:2064-2071.

Computerized provider order entry (CPOE) systems can reduce medication errors by alerting prescribers to a variety of potential adverse events. However, too many alerts may result in alert fatigue. This scoping review identified 16 studies on interventions to reduce alert fatigue. Most interventions focused on drug-drug interactions. A decrease in the quantity and frequency of alerts was seen as a positive outcome, however only four of the studies reported any patient safety outcomes.

Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.

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Kalfsvel L, Wilkes S, van der Kuy H, et al. Eur J Hosp Pharm. 2023;Epub Aug 31.

Even with the use of clinical decision support systems (CDSS), clinicians can still make medication prescribing errors. This study compared frequency, type, and severity of prescribing errors between junior doctors (i.e., those in training with less than 10 years’ work experience) and consultants (i.e., not in training with 10 or more years of work experience). Overall prescribing errors were low, but junior doctors made more errors than consultants. They also made different types of errors, with junior doctors more likely to make drug-drug interaction errors and consultants making duplication therapy errors. There were no differences in severity of errors. Early education and training with computerized provider order entry (CPOE) and CDSS may reduce errors made by doctors in training.

Inpatient EHR user experience and hospital EHR safety performance.

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Classen DC, Longhurst CA, Davis T, et al. JAMA Netw Open. 2023;6:e2333152.

Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

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Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

The impact of transition to a digital hospital on medication errors (TIME study).

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Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6:133.

Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

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WebM&M Case July 31, 2023

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion.

A hard look at hard stops and workarounds in the acute care setting.

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ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4.

Hard stops in the electronic medical record prevent continuation of ordering, dispensing, or administering an unsafe medication to a patient. This article presents system-level recommendations to effectively introduce hard stops such as including physicians and pharmacists in decision making to reduce risk of workarounds in the future.

A scoping review of legibility of hand-written prescriptions and drug-orders: the writing on the wall.

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Ariaga A, Balzan D, Falzon S, et al. Expert Rev Clin Pharmacol. 2023;16:617-621.

Illegible prescriptions can cause pharmacists to dispense incorrect medications resulting in patient harm. This review identified 15 studies on illegible prescriptions. Most of the studies were more than 10 years old and the authors acknowledge the advent of computerized provider order entry (CPOE) has reduced incidence of illegible prescriptions. However, CPOE relies on highly functional information technology systems which may be cost-prohibitive for some countries.

A "Do No Harm" novel safety checklist and research approach to determine whether to launch an artificial intelligence-based medical technology: introducing the Biological-Psychological, Economic, and Social (BPES) Framework.

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Khan WU, Seto E. J Med Internet Res. 2023;25:e43386.

Artificial intelligence (AI) and machine learning (ML) are emerging as tools to improve patient care, but they are not without risks. This article proposes use of a safety checklist to determine readiness to launch AI technologies, prompting users to consider physical and mental health and economic and social risks and benefits.

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

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Ye J. JMIR Periop Med. 2023;6:e34453.

Perioperative medication errors are common. This article highlights several interventions to reduce the risk of perioperative medication errors, including improved medication labeling, adoption of artificial intelligence for decision support and risk prediction, and the use of health information technology (IT), such as computerized physician order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA).

Impact of a computerized physician order entry system on medication safety in pediatrics-The AVOID study.

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Wimmer S, Toni I, Botzenhardt S, et al. Pharmacol Res Perspect. 2023;11:e01092.

Computerized physician order entry (CPOE) systems can prevent medication ordering and dispensing errors. This pre-post study compared medication safety outcomes for paper-based prescribing versus CPOE-based prescribing among pediatric patients at one German hospital. The researchers found that CPOE implementation resulted in fewer potentially harmful medication errors.

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

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Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.

Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.

Human factors and safety analysis methods used in the design and redesign of electronic medication management systems: a systematic review.

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Awad S, Amon K, Baillie A, et al. Int J Med Inform. 2023;172:105017.

Computerized provider order entry (CPOE), clinical decision support (CDS), and electronic medication management systems (EMMS) have increased efficiency and reduced prescribing errors, but poor design may introduce new safety hazards. Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally before problems arise. This review identifies human factors and safety analysis methods applied to EMMS. Most methods focused on usability or design, and only one used a safety-oriented approach. Increased inclusion of human factors specialists could increase the use of safety-oriented methods of EMMS design.

Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.

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Liang MQ, Thibault M, Jouvet P, et al. BMJ Health Care Inform. 2023;30(1):e100622.

Computerized provider order entry (CPOE) systems are widely used and can help prevent medication administration errors. This mixed-methods study examined the impact of CPOE on medication safety in the pediatric department at one Canadian hospital. Researchers found that most errors occurred during the medication administration step rather than the prescribing step. The researchers also observed a non-statistically significant decrease in medication errors overall, which was primarily attributed to significant improvements in errors during order acknowledgement, transmission, and transcription.

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

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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.

Technology as a Tool for Improving Patient Safety

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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.

Diagnostic stewardship to prevent diagnostic error.

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Morgan DJ, Malani PN, Diekema DJ. JAMA. 2023;329:1255-1256.

The effective use of resources through stewardship initiatives can support error reduction through focusing actions of care. This commentary discusses how diagnostic stewardship can enhance diagnostic testing behaviors across the diagnostic process.

Safety risks and workflow implications associated with nursing-related free-text communication orders.

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Staes CJ, Yusuf S, Hambly M, et al. J Am Med Inform Assoc. 2023;30:828-837.

Previous research has identified errors related to use of free-text fields in the electronic health record (EHR) systems. In this study, researchers examined potential safety hazards within free-text EHR communication orders sent to or from nurses. Analyses indicated that free-text orders did include symbols and abbreviations discouraged by the Institute for Safe Medication Practices (ISMP) and that future research should explore issues stemming from workarounds and EHR design.

The Leapfrog Hospital Survey.

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Leapfrog Group.

This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. The 2023 survey session opens April 1, 2023.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

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