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 3045 Results

Completion of recommended tests and referrals in telehealth vs in-person visits.

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Zhong A, Amat MJ, Anderson TS, et al. JAMA Netw Open. 2023;6:e2343417.

Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or referrals within the recommended timeframe can increase the risk of delayed diagnoses and patient harm.

Patient Safety Research Summaries.

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Rockville, MD: Agency for Healthcare Research and Quality; 2023.

The application of evidence in real situations helps to embed innovation across systems and sustain care improvement. This collection of project highlight reports shares descriptions of implementation projects and research funded by AHRQ. Topics covered include patient engagement, health information technology, and healthcare facility design.

Post-implementation optimization of medication alerts in hospital computerized provider order entry systems: a scoping review.

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Ledger TS, Brooke-Cowden K, Coiera E. J Am Med Inform Assoc. 2023;30:2064-2071.

Computerized provider order entry (CPOE) systems can reduce medication errors by alerting prescribers to a variety of potential adverse events. However, too many alerts may result in alert fatigue. This scoping review identified 16 studies on interventions to reduce alert fatigue. Most interventions focused on drug-drug interactions. A decrease in the quantity and frequency of alerts was seen as a positive outcome, however only four of the studies reported any patient safety outcomes.

Five strategies for a safer EHR modernization journey.

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Sittig DF, Yackel EE, Singh H. J Gen Intern Med. 2023;38:940-942.

Large-scale technology modifications can contribute to organizational disfunction. This commentary discusses five approaches to managing disruption associated with electronic health record modernization that establish cultural, functionality, staff, design, and monitoring conditions to reduce stress and the potential for patient harm during technology improvements.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

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Leon C, Hogan H, Jani YH. BMJ Qual Saf. 2023;Epub Nov 3.

Errors associated with high-risk medications (HRM) like insulin and anticoagulants carry a greater risk for harm. The purpose of this scoping review was to identify measures evaluating the safety of HRM during transitions of care. Measures were mapped to frameworks (e.g., Donabedian) and whether measures were reactive, proactive, or real-time. The authors describe ways technology can improve how the measures are implemented.

"ChatGPT, can you help me save my child's life?" - Diagnostic accuracy and supportive capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases - an in-silico analysis.

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Bushuven S, Bentele M, Bentele S, et al. J Med Syst. 2023;47:123.

ChatGPT has emerged as a potentially useful tool for clinicians and the public in obtaining heath advice and diagnosis. In this study, six iterations of 22 pediatric emergency vignettes were entered into ChatGPT (total of 132 scenarios) to assess diagnostic accuracy, emergency call advice, and validity of advice given. ChatGPT correctly recommended contacting medical professionals in all cases but only advised calling emergency medical services (EMS) or 911 in 12 of the 22 scenarios. The correct diagnosis was made in 94% of cases, consistent with other research into ChatGPT. Considerably more research is required before ChatGPT could be recommended for diagnostic advice.

Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration.

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List JM, Russell LE, Hausmann LRM, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 10.

Unmet health-related social needs (HRSNs; e.g., housing instability, food insecurity) and healthcare disparities can place patients at increased risk for patient safety incidents and poor outcomes. This article describes how existing Veterans Health Administration (VHA) initiatives to address HRSNs and disparities are being leveraged to address new Joint Commission standards to improve health care equity.

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

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WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

Medication Mix-Up Leads to Patient Death

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WebM&M Case November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

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Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

Digital health intervention on patient safety for children and parents: a scoping review.

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Park J, Jeon H, Choi EK. J Adv Nurs. 2023;Epub Nov 10.

Digital health tools are increasingly used to support the delivery of safe healthcare. This scoping review characterized 13 articles exploring the use of digital interventions intended to support patient safety among pediatric patients and their parents. Interventions were commonly delivered through mobile applications, web-based technologies, computer kiosks, and electronic health records, and focused on patient safety event prevention and risk management.

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study.

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Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.

Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.

Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.

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Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.

The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

Technology, Education and Safety

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Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.

Validation of a reduced set of high-performance triggers for identifying patient safety incidents with harm in primary care.

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Garzón González G, Alonso Safont T, Conejos Míquel D, et al. J Patient Saf. 2023;19:508-516.

Retrospective chart review is the standard for estimating prevalence of adverse events manual review of the electronic health record (EHR) is resource intensive. This study describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.

Doctors wrestle with A.I. in patient care, citing lax oversight.

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Jewett C. New York Times. October 30, 2023

US Food and Drug Administration regulation and review is noted as having gaps in process that can affect patient safety. This article discusses reasons for the reluctance of physicians to fully embrace the use of artificial intelligence tools approved by the FDA in their practice. The concerns include lax regulation, poor product development transparency and lack of robust real-world accuracy data.

Temporarily holding medication orders safely in order to prevent patient harm.

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ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.

Process disconnects can cause administration mistakes that lead to harm. This article discusses reasons for holding medications and how workflow issues can contribute to medication temporary stop order problems. Recommendations for improvement include examining electronic health record alerts, assigning one prescriber to oversee medication reconciliation, and instituting a policy on hold orders.

Assessing biases in medical decisions via clinician and AI chatbot responses to patient vignettes.

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Kim J, Cai ZR, Chen ML, et al. JAMA Netw Open. 2023;6:e2338050.

Artificial intelligence (AI) is increasingly used in healthcare, but concerns have been raised that it can exacerbate existing disparities because of underlying biases in AI tools. In this observational study, researchers evaluated biases in clinician versus AI chatbox responses to 19 clinical vignettes involving cardiology, emergency medicine, rheumatology, and dermatology. Findings indicate that both AI chatboxes and clinicians provide different clinical recommendations based on a patient’s gender, race/ethnicity, and socioeconomic status under certain clinical scenarios.

Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.

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Kalenderian E, Bangar S, Yansane A, et al. J Patient Saf. 2023;19:305-312.

Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.

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