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 642 Results

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

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Taft T, Rudd EA, Thraen I, et al. J Am Med Inform Assoc. 2023;Epub Mar 8.

Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.

Duplicate Therapies in Retail Pharmacy

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WebM&M Case March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.

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;Epub Feb 20.

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.

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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.

Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.

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Rennert L, Howard KA, Walker KB, et al. J Patient Saf. 2023;19:71-78.

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.

Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.

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Bell SK, Dong ZJ, DesRoches CM, et al. J Am Med Inform Assoc. 2023;Epub Jan 24.

Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.

Electronic health record use issues and diagnostic error: a scoping review and framework.

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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.

Assessment of the use of patient vital sign data for preventing misidentification and medical errors.

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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.

Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes.

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Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.

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.

Weight and size descriptors for drug dosing: too many options and too many errors.

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Erstad BL, Romero AV, Barletta JF. Am J Health Syst Pharm. 2023;80:87-91.

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.

Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act.

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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.

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.

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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%).

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

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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.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

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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.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care.

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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.

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

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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.

Professional behavior and value erosion: a qualitative study of physicians and the electronic health record.

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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.

Documenting the indication for antimicrobial prescribing: a scoping review.

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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.

The impact of meaningful use and electronic health records on hospital patient safety.

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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.

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