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 1810 Results

Improving Patient Safety with Human Factors Methods.

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Armstrong Institute for Patient Safety and Quality, Baltimore, MD. October 3-4, 2023.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

A "Do No Harm" novel safety checklist and research approach to determine whether to launch an artificial intelligence-based medical technology: introducing the Biological-Psychological, Economic, and Social (BPES) Framework.

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Khan WU, Seto E. J Med Internet Res. 2023;25:e43386.

Artificial intelligence (AI) and machine learning (ML) are emerging as tools to improve patient care, but they are not without risks. This article proposes use of a safety checklist to determine readiness to launch AI technologies, prompting users to consider physical and mental health and economic and social risks and benefits.

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

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Ye J. JMIR Periop Med. 2023;6:e34453.

Perioperative medication errors are common. This article highlights several interventions to reduce the risk of perioperative medication errors, including improved medication labeling, adoption of artificial intelligence for decision support and risk prediction, and the use of health information technology (IT), such as computerized physician order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA).

Developing electronic clinical quality measures to assess the cancer diagnostic process.

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Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.

Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.

Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training.

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Kennedy GAL, Pedram S, Sanzone S. Safety Sci. 2023;165:106200.

Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.

Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review.

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Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.

Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.

Taking a closer look at medication errors that involve oxytocin.

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ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6.

Oxytocin, which is commonly used to induce labor, has been associated with adverse events. Based on 2,073 oxytocin-related medication errors reported to one patient safety organization, the authors of this article summarize the common event types (e.g., pump misprogramming, incorrect infusion set-up, or use of incorrect drug or concentration) and highlight several recommendations to increase safe oxytocin administration.

Towards safe conversational agents in healthcare.

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Denecke K. Stud Health Technol Inform. 2023;302:157-161.

The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.

The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study.

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Tataei A, Rahimi B, Afshar HL, et al. BMC Health Serv Res. 2023;23:527.

Patient handoffs present opportunities for miscommunication and errors. This quasi-experimental study examined the impact of an electronic nursing handover system (ENHS) on patient safety and handover quality among patients both with and without COVID-19 in the intensive care unit (ICU). Findings indicate that the ENHS improved the quality of the handover, reduced handover time, and increased patient safety.

Adolescents identifying errors and omissions in their electronic health records: a national survey.

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Hagström J, Blease CR, Kharko A, et al. Stud Health Technol Inform. 2023;302:242-246.

Patients are increasingly able to access their health record via electronic patient portals and many report finding errors in the record. This study asked adolescent (ages 15-19) patient portal users if they had identified errors or omissions in their record, and if so, did they report them to their provider. Approximately one-quarter of patients identified an error and 20% identified an omission. The majority of those patients did not report it to the clinic or healthcare provider.

Impact of a computerized physician order entry system on medication safety in pediatrics-The AVOID study.

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Wimmer S, Toni I, Botzenhardt S, et al. Pharmacol Res Perspect. 2023;11:e01092.

Computerized physician order entry (CPOE) systems can prevent medication ordering and dispensing errors. This pre-post study compared medication safety outcomes for paper-based prescribing versus CPOE-based prescribing among pediatric patients at one German hospital. The researchers found that CPOE implementation resulted in fewer potentially harmful medication errors.

Classification of health information technology safety events in a pediatric tertiary care hospital.

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Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.

For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

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Coghlan A, Turner S, Coverdale S. Intern Med J. 2023;53:550-558.

Use of abbreviations in electronic health records increases risk of misunderstandings, particularly between providers of different specialties. In this study, junior doctors and general practitioners were asked about their understanding of common, uncommon, and rare abbreviations used in hospital discharge notes. No abbreviation was interpreted in the same way by all respondents, and nearly all respondents left at least one abbreviation blank or responded that they didn't know.

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study.

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Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.

Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

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Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.

Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

Human factors and safety analysis methods used in the design and redesign of electronic medication management systems: a systematic review.

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Awad S, Amon K, Baillie A, et al. Int J Med Inform. 2023;172:105017.

Computerized provider order entry (CPOE), clinical decision support (CDS), and electronic medication management systems (EMMS) have increased efficiency and reduced prescribing errors, but poor design may introduce new safety hazards. Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally before problems arise. This review identifies human factors and safety analysis methods applied to EMMS. Most methods focused on usability or design, and only one used a safety-oriented approach. Increased inclusion of human factors specialists could increase the use of safety-oriented methods of EMMS design.

Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.

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Allen G, Setzer J, Jones R, et al. Jt Comm J Qual Patient Saf. 2023;49:247-254.

Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

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