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 677 Results

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.

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.

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.

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose.

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WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

“Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records.

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WebM&M Case October 31, 2023

This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition.

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Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.

Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Unintended consequences of the electronic health record and cognitive load in emergency department nurses.

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Harmon CS, Adams SA, Davis JE, et al. Appl Nurs Res. 2023;73:151724.

Electronic health records increase safety in many ways but are not without problems. In this survey, emergency department nurses reported that electronic health record (EHR) issues (downtime, workflow) negatively impacted patient safety such as documentation or orders placed on the wrong patient chart.

Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.

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Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

Abbreviation use decreases effective clinical communication and can compromise patient safety.

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Parry D, Odedra A, Fagbohun M, et al. Br J Oral Maxillofac Surg. 2023;61:509-513.

Misleading or unclear abbreviations can cause communication errors and threaten patient safety. This article highlights how lessons learned regarding abbreviations in aviation can apply to healthcare to avoid abbreviation-related medical errors, such as prescribing errors.

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

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Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;Epub Aug 21.

Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study.

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Li E, Lounsbury O, Clarke J, et al. BMC Med Inform Decis Mak. 2023;23:158.

Shortfalls in electronic health record (EHR) interoperability can threaten patient safety. Chief clinical information officers (CCIOs) participating in semi-structured interviews highlighted the ways in which limited EHR interoperability adversely impacts patient health and safety by hindering care coordination and creating inefficient care processes. Participants noted that solutions are necessary at both the technical (e.g., user-centered design) and policy levels.

The delivery of safe and effective test result communication, management and follow-up.

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Georgiou A, Li J, Thomas J, et al. Public Health Res Pract. 2023;33:e3332324.

Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Pharmacy e-prescription dispensing before and after CancelRx implementation.

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Pitts SI, Olson S, Yanek LR, et al. JAMA Intern Med. 2023;183:1120-1126.

Previous research has found that CancelRx can improve communication between electronic health record (EHR) systems and pharmacy dispensing systems and increase successful medication discontinuation. This interrupted time series analysis assessed the impact of CancelRx implementation on successful discontinuation of medications e-prescribed in ambulatory healthcare settings. After CancelRx implementation, the proportion of e-prescriptions sold after discontinuation in the EHR decreased from 8.0% to 1.4%.

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

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Grubenhoff JA, Bakel LA, Dominguez F, et al. Jt Comm J Qual Patient Saf. 2023;49:547-557.

Clinical care pathways (CP) standardize care to ensure evidence-based practices are consistently followed. This study analyzed missed diagnostic opportunities (MDO) of pediatric musculoskeletal infections that could have been mitigated had the CP recommendations been adhered to. Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic consultants.

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients.

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Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

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Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

Differential perceptions of what constitutes a medical error associated with electronic medical records.

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Koppel R, Kuziemsky C, Elkin PL, et al. Stud Health Technol Inform. 2023;304:21-25.

Health information technology (HIT) has improved many aspects of patient safety, but poor design can result in patient harm. This commentary describes how context influences vendor, organization, and user understanding of HIT-related errors and proposes system-level solutions, in particular a focus on user-centered design.

The impact of transition to a digital hospital on medication errors (TIME study).

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Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6:133.

Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.

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