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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 577 Results
Patient Safety Innovation November 16, 2022

While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to identify and reduce the number of alerts clinicians encounter every day. 

Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.
Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;Epub Sep 5.
Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.
Ünal A, Seren Intepeler Ş. J Patient Saf. 2022;18:e1102-e1108.
Increasing patient safety event reporting is an ongoing priority. This article summarizes the trends in medical error reporting and reporting system research from 1970 to 2021. While the number of publications increased annually, researchers observed a lack of cross-country collaboration on studies evaluating error reporting systems.
Skeff KM, Brown-Johnson CG, Asch SM, et al. J Healthc Manag. 2022;67:339-352.
Electronic health records (EHRs) can improve patient safety but can also contribute to physician burnout. This qualitative study involving physicians and medical trainees found that distress most often occurred when physicians were prioritizing systems-based practice (e.g., EHR-required documentation) over other professional activities, such as patient care, communication, and practice-based learning.  
Kawsar M, Linander I. Sex Reprod Healthc. 2022;34:100786.
Trans and gender-nonconforming (TGNC) people may delay or avoid seeking healthcare due to experiences with biased or uninformed providers. This study focuses specifically on obstetric and gynecological care providers who provide care to TGNC people. Participants described challenges at the clinic level (e.g., needing at least one knowledgeable and interested clinician) and administrative level (e.g., trans men who have a cervix do not get automatic reminders for PAP tests) that can prevent TGNC people from receiving equitable care.
Karanikas N, Khan SR, Baker PRA, et al. Safety Sci. 2022;156:105906.
Some patient safety interventions, such as checklists, are adapted or borrowed from other industries, such as aviation. This literature review focused on safety interventions developed in one context then implemented in another, such as healthcare. Healthcare was the largest sector represented, with 20 of the 73 included studies.
Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.
The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.
Seys D, De Decker E, Waelkens H, et al. J Patient Saf. 2022;18:717-721.
Burnout and stress among healthcare workers can adversely impact patient safety. Using data from two cross-sectional surveys, this study found the COVID-19 pandemic had a larger impact on the mental health and well-being of healthcare workers compared to involvement in a patient safety incident. Negative psychological symptoms such as anxiety, sleep deprivation, and wanting to leave the profession were all significantly higher in COVID-19-related groups. 
Bocknek L, Kim T, Spaar P, et al. Patient Safety. 2022;4:39-47.
Duplicate medication orders, defined as orders for two or more identical medications or same therapeutic class, can result in serious complications if they reach the patient. This study examined the error type (same medication, therapeutic class, or order), when they were recognized, and factors contributing to the error. Importantly, of duplicate orders in the same therapeutic class, the three most common medications were anti-coagulants, a high-risk medication.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Pitts SI, Yang Y, Woodroof T, et al. J Patient Saf. 2022;18:e934-e937.
CancelRx is a health information tool designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. This study found that CancelRx implementation eliminated the sale of electronically prescribed medications after discontinuation in the EHR, compared to prior to implementation. Researchers found that CancelRx did result in the unintentional cancellation of some prescriptions and they discuss the importance of situational awareness among providers and pharmacy staff to mitigate this issue.
Sexton JB, Adair KC, Proulx J, et al. JAMA Netw Open. 2022;5:e2232748.
The COVID-19 pandemic increased symptoms of physician burnout, including emotional exhaustion, which can increase patient safety risks. This cross-sectional study examined emotional exhaustion among healthcare workers at two large health care systems in the United States before and during the COVID-19 pandemic. Respondents reported increases in emotional exhaustion in themselves and perceived exhaustion experienced by their colleagues. The researchers found that emotional exhaustion was often clustered in work settings, highlighting the importance of organizational climate and safety culture in mitigating the effects of COVID-19 on healthcare worker well-being.
Hodkinson A, Zhou, A, Johnson J, et al. BMJ. 2022;378:e070442.
Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.
Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2022;Epub Jul 6.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.
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.
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgery. 2022;172:537-545.
The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.
Nijor S, Rallis G, Lad N, et al. J Patient Saf. 2022;18:e999-e1003.
Usability issues related to electronic health record (EHR) use among clinicians can contribute to burnout and threaten patient safety. This literature review outlines how EHR usability issues, such as information overload, can lead to errors and threaten patient safety. The authors suggest that future research explore methods to mitigate EHR overload-related errors, including the role of EHR usability.
Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2023;38:55-60.
Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).
Taylor DJ, Goodwin D. J Med Ethics. 2022;48:672-677.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.