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 1806 Results

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.

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;Epub Feb 20.

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.

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.

A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics.

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Patient Safety Innovation March 29, 2023

Improving non-technical skills - such as teamwork and communication – is essential to safe delivery of healthcare but implementing successful training programs has been challenging.

Reducing hospital harm: establishing a command centre to foster situational awareness.

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Patient Safety Innovation March 29, 2023

Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.

"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.

I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.

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Tamayo-Sarver J. Fast Company. March 13, 2023.

Artificial intelligence (AI) harbors risks and biases that can misinform clinicians, researchers, and patients. This article discusses experience with an AI application in the emergency setting and the diagnostic mistakes it made. The author offers caution when proceeding with the use of AI as a diagnostic tool.

Automated capture of intraoperative adverse events using artificial intelligence: a systematic review and meta-analysis.

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Eppler MB, Sayegh AS, Maas M, et al. J Clin Med. 2023;12:1687.

Real-time use of artificial intelligence in the operating room allows surgeons to avoid or immediately address intraoperative adverse events. This review summarizes 13 articles published since 2010 that report on the use of artificial intelligence to predict intraoperative adverse events. Most studies used video and more than half were intended to detect bleeding.

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.

An infrastructure to provide safer, higher quality, and more equitable telehealth.

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Kobeissi MM, Hickey JV. Jt Comm J Qual Patient Saf. 2023;49:213-222.

The COVID-19 pandemic led to the rapid expansion and adoption of telehealth. The authors of this article discuss how to leverage the increased use of telehealth and propose a new organizational telehealth program model to help organizations develop and sustain safe, equitable, and high-quality telehealth programs.

Artificial intelligence, patient safety, and achieving the quintuple aim in anesthesiology.

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Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.

Technological advancement is a hallmark of anesthesiology safety improvement. This article discusses the opportunities that artificial intelligence (AI) represents for anesthesiologists and provides a practical framework for understanding the important relationship to be optimized between AI and perioperative care to support patient safety.

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.

Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.

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Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022.

The potential of machine learning to improve care and safety is emerging as its application increases across health care. This report examines how machine learning can improve activities such as risk identification and prediction. It also discusses barriers to its use such as workload, expertise gaps, and system integration.

Health technology, quality and safety in a learning health system.

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Borycki EM, Kushniruk AW. Healthc Manage Forum. 2023;51:212-221.

Health technology has improved many aspects of care, but can also introduce new safety concerns that require active monitoring and improvement. This commentary describes how learning health systems can improve the safety of new technologies, such as hiring health informaticists and collaborations with health authorities and vendors.

A customized triggers program: a children's hospital's experience in improving trigger usability.

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Reinhart RM, Safari-Ferra P, Badh R, et al. Pediatrics. 2023;151:e2022056452.

Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.

Using automated methods to detect safety problems with health information technology: a scoping review.

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Surian D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2022;30:382-392.

Health information technology (HIT), such as electronic health records (EHRs) or computerized provider order entry (CPOE) systems, are important approaches to improving safety. This scoping review of 45 articles found that machine learning and statistical modeling are the most commonly used automated, HIT-based methods for early detection of safety threats. Machine learning was often used to detect errors occurring in laboratory test results, prescriptions, and patient records. Statistical modeling was used to detect issues with clinical decision support systems.

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.

Bending the patient safety curve: how much can AI help?

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Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.

Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.

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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