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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 37 Results
Luri M, Gastaminza G, Idoate A, et al. J Patient Saf. 2022;18:630-636.
Clinical decision support systems can alert prescribers to potential interactions between the drug being ordered and other drugs or drug allergies. Earlier studies have shown high rates of overrides of drug allergy alerts. This study analyzed allergic adverse drug events that occurred because of overridden drug allergy alerts (ODAA). Less than 10% of ODAA were inappropriate and resulted in only mild adverse events.
Olans RD, Olans RN, Marfatia R, et al. Jt Comm J Qual Patient Saf. 2022;48:552-558.
Inadequate or incorrect documentation of patient allergies can lead to patient harm. This commentary discusses factors contributing to penicillin allergy documentation errors within electronic heath record systems (EHRs) and how EHR alerts can be used to improve safety around penicillin allergies.
Howe LC, Hardebeck EJ, Eberhardt JL, et al. Proc Natl Acad Sci USA. 2022;119:e2007717119.
Providers’ gender, racial, and ethnic bias can adversely affect patient safety and lead to poor outcomes. This study investigated white patients’ physiological responses to treatment provided by either a woman or Black physician. Despite patients’ positive overt attitudes to Black or woman physicians, they were less physiologically responsive to placebo treatment provided by women or Black physicians, suggesting additional implications for health inequities.
Vallamkonda S, Ortega CA, Lo YC, et al. Stud Health Technol Inform. 2022;290:120-124.
Prior research has found that electronic health record (EHR) implementation has introduced risks to patient safety. Using data from one hospital’s EHR system, this study reviewed active allergy alerts in patient records and concluded that 37% of those records required reconciliation of allergy information across different areas of the EHR. These findings highlight the need for automated reconciliation algorithms and clinical decision support tools to help clinicians identify potential allergy discrepancies and avoid patient safety risks.
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;10:1844-1855.e3.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels. 
Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.
Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.

Safety professionals encourage learning from errors to enhance the safe use of new processes and products. This article reviews vaccine error experiences and provides insight for the implementation of the COVID vaccine to help practitioners plan and activate safe vaccination processes.
Samad F, Burton SJ, Kwan D, et al. Pharmaceut Med. 2021;35:1-9.
Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.
Abrams EM, Shaker M, Oppenheimer J, et al. J Allergy Clin Immunol Pract. 2020;8:2474-2480.e1.
This article discusses the challenges COVID-19 poses for shared decision making (such as physical distancing and health service reallocation, communicating uncertainty, delivering allergy/immunology care) and opportunities to evolve incorporation of shared decision making into clinical practice during and after the pandemic.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
Inconsistent checking for and consideration of drug allergy alerts can diminish the safety of prescribing. This report from a multistakeholder work group provides evidence-based safe practices and recommendations for improvement, including standardizing documentation practices, actionable decision support, monitoring of alert effectiveness, and patient engagement.

ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.

Mistakes in the use of vaccines can have both individual and public health implications. The first article of this series reviews the results from an analysis of reports submitted to the National Vaccine Errors Reporting Program to track vaccine-related errors. The second article offers recommendations to help immunization and vaccination programs address product-, knowledge-, and practice-related factors that contribute to process weaknesses, including training, storage, and labeling strategies.
Sicherer SH, Allen K, Lack G, et al. Pediatrics. 2017;140.
Diagnostic error can result in physical, psychological, and financial patient harm. This commentary discusses key findings of a consensus report and highlights challenges associated with diagnosing and treating food allergies. The authors recommend process changes and research directions to help improve allergy identification and management specific to pediatric care.
WebM&M Case April 1, 2017
Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.
WebM&M Case March 1, 2017
Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization.
Topaz M, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2016;23:601-608.
Alert fatigue is recognized as a barrier to patient safety and may particularly increase risks associated with medication prescribing. This study examined the frequency of manual overrides of alerts for medication allergies over a 10-year period. Clinicians were required to provide a reason for overriding the allergy alert. As with earlier studies, the rate of overrides was very high. Researchers determined that the alerts were irrelevant in more than half the cases. Providers also were more likely to override repeated alerts compared with new alerts. These results highlight the overuse of alerts in health care settings and the need to improve their use to effectively support patient safety.
Shell ER. Scientific American. 2015;313:28-9.
Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to detect allergies and a desensitization process to reduce incidence of allergies in children.
WebM&M Case October 1, 2015
After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic.
Hibbs BF, Moro PL, Lewis P, et al. Vaccine. 2015;33:3171-3178.
Vaccination-related errors reported to the National Vaccine Adverse Event Reporting System grew from 10 in the year 2000 to 4324 in 2013, potentially due to the introduction of new vaccines, increasingly complex vaccination schedules, and changes in reporting practices. The most common errors were dispensing vaccines at an inappropriate schedule or administering expired or incorrectly stored vaccines. One-fourth of reported errors caused an adverse health event, with 8% of these resulting in serious harm.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;20:1-4.

This newsletter series reports on 2 years of data collected during a national effort to collect vaccine administration errors. The first article summarizes information about the types of vaccine errors reported and why they occur. The second article discusses risks during vaccine use and offers recommendations to prevent them.