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.
Abraham J, Kitsiou S, Meng A, et al. BMJ Qual Saf. 2020;29:854–863.
This systematic review of the cumulative effect of computerized provider order entry (CPOE) identified significant decreases in medication errors and adverse drug events in inpatient settings but the authors note considerable variation in the magnitude of risk reduction. No significant reductions in inpatient mortality or length of stay were identified.
Howlett MM, Butler E, Lavelle KM, et al. Appl Clin Inform. 2020;11.
Using a pre-post approach, this study assessed the impact of implementing electronic prescribing and smart pump-facilitated standard concentration infusions on medication errors in a pediatric intensive care unit (PICU). The overall error rates were similar before and after implementation but the error types changed before and after implementation of these tools. After implementation, lack of clarity, incomplete orders and wrong unit errors were reduced but dosing errors, altered orders and duplicate errors increased. Pre-implementation, 78% of errors were deemed preventable by electronic prescribing and smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred if the order was not electronically created or administered via the smart-pump.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Info Assoc. 2020;27:924-928.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.
Austin J, Barras M, Sullivan C. Int J Med Inform. 2020;135.
The authors systematically reviewed the evidence on electronic health record (EHR) interventions designed to improve the safety and quality of anticoagulation administration in inpatient hospitals settings. The 27 articles meeting inclusion criteria examined four types of interventions: computerized physician order entry (CPOE), clinical decision support systems (CDSS), dashboards, and general EHR implementation. Included studies reported reductions in medication errors and adverse drug events with use of CPOE and CDDS, but studies did not find benefits to other adverse events (e.g., bleeding events), readmissions or length of stay. Overall, the review found limited evidence demonstrating the benefit of inpatient EHR interventions in improving anticoagulation safety and quality.
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