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 595 Results

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 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 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 "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.

Examining medication ordering errors using AHRQ Network of Patient Safety Databases.

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Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;30:838-845.

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

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.

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

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Chew MM, Rivas S, Chesser M, et al. J Patient Saf. 2023;19:23-28.

Provision of enteral nutrition (EN) is a specialized process requiring careful interdisciplinary teamwork. After discovering significant issues with ordering, administration, and documentation of EN, this health system updated its workflows to improve safety. EN therapies were added to the electronic medication administration record (MAR) and the barcoding system was updated. After one year, all EN orders were barcode scanned and nearly all were documented as given or included a reason why they were not given.

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