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.
Dr. Arora is Director of GME Clinical Learning Environment Innovation and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. We spoke with her about the intersection of health information technology and patient safety.
A woman with new onset chest pain was admitted to the hospital. Although the computer readout of her electrocardiogram stated "***ACUTE MI***" at the top, the nursing assistant who performed the test placed it in the patient's bedside chart without notifying a nurse or physician. The patient was, in fact, having a myocardial infarction, whose treatment was delayed.
Mathew G, Kho A, Dexter P, et al. J Patient Saf. 2012;8:69-75.
Adverse events after hospital discharge are a continued threat to patient safety and the basis for interventions targeting key contributing factors. Premature discharge is an area less studied, partly because the decision-making for safe discharge falls on individual providers and their clinical assessment. This study developed a set of triggers based on selected laboratory abnormalities that could systematically identify patients potentially unsafe for discharge. Triggers that led to a discharge alert included an elevated white blood cell count, a rising creatinine level, specific abnormalities in electrolytes, and an elevated international normalized ratio (INR) in the absence of anticoagulant therapy. The discharge filter tool requires further validation, but it represents an innovation that leverages computerized systems to provide safer care.
An electronic system was developed in order to ensure correct assignment of hospitalist physicians to patients at admission and at the time of care transitions (e.g., discharge from the intensive care unit).
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Jen W-Y, Chao C-C. Int J Med Inform. 2008;77:689-97.
This study discovered that use of mobile patient safety information systems can contribute to improvement in services and a reduction in patient risk, but these communication systems may also contribute to physician anxiety.
A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
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