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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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Perspective on Safety March 30, 2020
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
Wright A, Ai A, Ash J, et al. J Am Med Inform Assoc. 2018;25:496-506.
Clinical decision support (CDS) includes electronic alerts that can prevent errors. Excessive or erroneous alerts may lead to alert fatigue or other unintended consequences. Researchers used a blend of qualitative methods such as interviews and quantitative data like alert rates to develop a taxonomy of CDS alert errors. The taxonomy includes the origin of the error, which most commonly occurred with introduction of a new decision support rule, and describes the underlying reason for the error, such as problems with new terms, conceptualization, and building the rule as intended. Errors could cause an alert to fail to appear for a relevant situation or could cause an irrelevant or erroneous alert to appear. Most errors came to light through reports from users. The authors recommend classifying CDS alert errors using this taxonomy so that safety efforts will be consistent and actionable.