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 125 Results

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

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Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jun 24.

Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

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Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

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.

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

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Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.

Causes of adverse events in home mechanical ventilation: a nursing perspective.

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Lipprandt M, Liedtke W, Langanke M, et al. BMC Nurs. 2022;21:264.

Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur at levels similar to hospitals. This study explored adverse events related to home mechanical ventilation (HMV), in order to categorize causes and recommend solutions. Interventions for nurses (e.g., checklists) and manufacturers (e.g., alarm design) may improve HMV.

The potential for leveraging machine learning to filter medication alerts.

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Liu S, Kawamoto K, Del Fiol G, et al. J Am Med Inform Assoc. 2022;29:891-899.

Alert fatigue contributes to task burden and can threaten patient safety. In this study, researchers at one academic medical center found that machine learning techniques could enable intelligent filtering of medication alerts and reduce alert volume by 54%.

Habit and automaticity in medical alert override: cohort study.

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Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.

Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

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Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2022;64:126-142.

Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

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ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.

An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology.

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Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17:56-62.

Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting.

Emergency department monitor alarms rarely change clinical management: an observational study.

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Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38:1072-1076.

In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.

Lessons learned from medical malpractice claims involving critical care nurses.

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Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.

This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

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Co Z, Holmgren AJ, Classen DC, et al. J Am Med Inform Assoc. 2020;27:1252-1258.

Using data from the Computerized Physician Order Entry (CPOE) Evaluation Tool, this study compared hospital performance against fatal orders and nuisance orders. From 2017 to 2018, overall performance increased and fatal order performance improved slightly; there was no significant change in nuisance order performance; however, these results indicate that fatal alerts are not being prioritized and that over-alerting in some cases may be contributing to alert fatigue.

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

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Powell L, Sittig DF, Chrouser K, et al. JAMA Netw Open. 2020;3:e206752-e.

Using root cause analysis data submitted to the Veterans Affairs (VA) National Center for Patient Safety from 2013 to 2018, this study analyzed health information technology (HIT)-related outpatient diagnostic delays to identify common safety concerns. The study identified five high-risk areas for diagnostic delays involving HIT: managing electronic health record inbox notifications and communications, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.

Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital.

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Pater CM, Sosa TK, Boyer J, et al. BMJ Qual Saf. 2020;29:717-726.

Continuous vital sign monitoring can generate a large volume of alarm notifications that may not represent meaningful change in clinical status and can lead to alarm fatigue, which has become a patient safety priority. This article describes Plan-Do-Study-Act processes employed in the acute care cardiology unit of a large, urban academic medical center that resulted in a reduction in alarm notifications of 68% over 2.5 years. Patient safety was maintained as these improvements were made and reductions in alarm notifications were sustained for more than 18 months.

Team-based intervention to reduce the impact of nonactionable alarms in an adult intensive care unit.

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Yeh J, Wilson R, Young L, et al. J Nurs Care Qual. 2019;35:115-122.

Prior research has found that nonactionable alarms are common and contribute to alarm fatigue among providers in intensive care units. This single center study employed an interprofessional team-based approach to adjust the default thresholds for arrhythmias and specific parameters such as oxygen saturation, which resulted in a nearly 47% reduction in nonactionable alarms over a two-week period.

Alert Fatigue

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Patient Safety Primer September 7, 2019

Computerized warnings and alarms are used to improve safety by alerting clinicians of potentially unsafe situations. However, this proliferation of alerts may have negative implications for patient safety as well.

Solving alarm fatigue with smartphone technology.

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Short K, Chung YJ. Nursing (Brux). 2019;49:52-57.

Alarm fatigue contributes to distraction and can diminish care safety. This commentary reviews a single-center project that used smartphone technology to enhance cardiac monitoring. The authors describe the structure of the project, use of Plan-Do-Study-Act cycles to design the application, results of the pilot, and plans to expand the use of this technology to other units and broaden monitoring targets. A WebM&M commentary discussed harm associated with alarm fatigue.

Managing alarm systems for quality and safety in the hospital setting.

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Bach TA, Berglund L-M, Turk E. BMJ Open Qual. 2018;7:e000202.

Alarm fatigue limits the utility of physiologic monitoring devices intended to keep hospitalized patients safe. The authors conducted a literature review and interviewed experts to identify best practices to optimize device alarms. They present a step-by-step guide to alarm improvement that incorporates a human factors engineering approach.

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward.

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Buckley MS, Rasmussen JR, Bikin DS, et al. Ther Adv Drug Saf. 2018;9:207-217.

This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.

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