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 647 Results

Adolescents identifying errors and omissions in their electronic health records: a national survey.

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Hagström J, Blease CR, Kharko A, et al. Stud Health Technol Inform. 2023;302:242-246.

Patients are increasingly able to access their health record via electronic patient portals and many report finding errors in the record. This study asked adolescent (ages 15-19) patient portal users if they had identified errors or omissions in their record, and if so, did they report them to their provider. Approximately one-quarter of patients identified an error and 20% identified an omission. The majority of those patients did not report it to the clinic or healthcare provider.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

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Bourne RS, Jeffries M, Phipps DL, et al. BMJ Open. 2023;13:e066757.

Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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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.

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

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Coghlan A, Turner S, Coverdale S. Intern Med J. 2023;53:550-558.

Use of abbreviations in electronic health records increases risk of misunderstandings, particularly between providers of different specialties. In this study, junior doctors and general practitioners were asked about their understanding of common, uncommon, and rare abbreviations used in hospital discharge notes. No abbreviation was interpreted in the same way by all respondents, and nearly all respondents left at least one abbreviation blank or responded that they didn't know.

Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries.

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Armstrong AA. J Healthc Qual. 2023;45:125-132.

Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions, and lower quality of life. This article describes the experience of one hospital which, after it discovered it had higher-than-average HAPI rates, conducted a root cause analysis to determine contributing factors and identify potential solutions. Dedicated nursing staff were hired and trained, and an electronic health record form was developed to document and track HAPI. A root cause analysis was completed for each HAPI to identify trends and implement improvements.

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study.

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Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.

Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.

Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety.

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Seeburger EF, Gonzales R, South EC, et al. JAMA Netw Open. 2023;6:e239057.

Verbal or physical violence towards healthcare workers can result in harm of both staff and patients. Based on semi-structured interviews with 25 registered nurses working in the emergency department (ED) at one large academic health system, the authors explored nursing perspectives on how EHR-based behavioral flags – used to identify incidents of workplace violence – can promote clinician safety. Participants identified benefits of the flags as well as concerns (e.g., introduction of bias, potential damage to the patient-clinician relationship), highlighted necessary system improvements, and how related challenges in the ED (e.g., unmet mental health needs of patients, COVID-19-related burnout) can contribute to workplace violence.

Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.

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Allen G, Setzer J, Jones R, et al. Jt Comm J Qual Patient Saf. 2023;49:247-254.

Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

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Muoio D. Fierce Healthcare. April 21, 2023.

Notable problems have occurred during the testing of the new electronic health records (EHR) system being designed for use in Veterans Affairs hospitals. This news article discusses the temporary halt of the project as the Department reassesses issues that have arisen during test rollouts in several United States hospitals.

Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis.

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Krevat S, Samuel S, Boxley C, et al. JAMA Netw Open. 2023;6:e238399.

The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.

The Danger of 10% Intravenous Calcium Chloride Extravasation.

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WebM&M Case April 26, 2023

This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical amputation of the patient’s left fourth (ring) finger. The commentary discusses the importance of correctly identifying IV fluids as irritants or vesicants, risks associated with the use of vesicants such as calcium chloride, and the role of early recognition of infiltration and extravasation and symptom management to minimize tissue damage and accelerate healing.

Adopting high reliability organization principles to lead a large scale clinical transformation.

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Pozzobon LD, Lam J, Chimonides E, et al. Healthc Manage Forum. 2023;Epub Apr 6.

High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.

Imagining the future of diagnostic performance feedback.

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Rosner BI, Zwaan L, Olson APJ. Diagnosis (Berl). 2023;10:31-37.

Peer feedback is an emerging approach to improving clinicians’ diagnostic reasoning skills. The authors outline several barriers to diagnostic performance feedback and propose solutions to improve diagnostic performance.

Racism and electronic health records (EHRs): perspectives for research and practice.

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Emani S, Rodriguez JA, Bates DW. J Am Med Inform Assoc. 2023;30:995-999.

Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.

Quality and safety: learning from the past and (re)imagining the future.

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Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.

Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.

Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.

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Donovan-Smith O. Spokesman Review. March 15, 2023.

Implementations of electronic health record (EHR) systems are complex efforts that have the potential for injury, should failure occur. This article discusses the Veterans Affairs EHR implementation project that is associated with six incidents of patient harm and calls for improvement at the federal level.

Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.

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Yasrebi-de Kom IAR, Dongelmans DA, de Keizer NF, et al. J Am Med Inform Assoc. 2023;30:978-988.

Prediction models are increasingly used in healthcare to identify potential patient safety events. This systematic review including 25 articles identified several challenges related to electronic health record (EHR)-based prediction models for adverse drug event diagnosis or prognosis, including adherence to reporting standards, use of best practices to develop and validate prediction models, and absence of causal prediction modeling.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

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Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

"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;30:809-818.

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.

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