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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 - 8 of 8 Results
Prgomet M, Li L, Niazkhani Z, et al. J Am Med Inform Assoc. 2017;24:413-422.
While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.
HIM J. 2015;44.
This quality improvement study to enhance the safety of chemotherapy was conducted at a tertiary care hospital in Pakistan. Investigators found that standardized chemotherapy orders within a computerized provider order entry system were associated with fewer medication errors as well as improved dispensing efficiency compared with the older, paper-based order system.
Lee JH, Han H, Ock M, et al. Int J Med Inform. 2014;83.
This before-and-after study found that clinical decision support reduced medication errors (greater than maximum dose) for five high-alert medications. Changes in order patterns emerged following the alerts, but the authors did not identify patient harm associated with the system. This work supports the use of clinical decision support for high-risk medications.
Ahn EK, Cho S-Y, Shin D, et al. Healthc Inform Res. 2014;20:280-7.
Alert fatigue is a well-described limitation of clinical decision support systems. This qualitative study found alert overrides occurred most frequently in the emergency department, and the most common reason reported was that the alert was clinically irrelevant, emphasizing the need to tailor alerting systems for different clinical settings.
Kadmon G, Bron-Harlev E, Nahum E, et al. Pediatrics. 2009;124:935-940.
Hospitalized children are particularly vulnerable to medication errors due to the complexity of weight-based dosing and the resulting potential for calculation errors. Computerized provider order entry (CPOE) has been widely advocated as a means of preventing such errors. In this study, implementation of a CPOE system did not initially reduce adverse drug events in a pediatric intensive care unit. However, when a decision support system for calculating weight-based dosages was added to the CPOE system, medication errors declined significantly. A 2008 Sentinel Event Alert published by The Joint Commission highlighted the prevalence of pediatric medication errors and recommended potential solutions.