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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 51 Results
Patient Safety Innovation June 14, 2023

To address a well-documented hospital adverse outcome (in-hospital patient clinical deterioration), Kaiser Permanente Northern California (KPNC) developed and implemented the Advance Alert Monitor (AAM) program. Using predictive analytics, the team developed a model to alert clinicians up to 12 hours prior to a patient’s likely deterioration. This early detection allowed clinicians to devise and implement a care plan to prevent deterioration of the patient’s condition and/or align the care plan with the goals of the patient.

Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Kern-Goldberger AR, Nicholls EM, Plastino N, et al. Am J Obstet Gynecol MFM. 2023:100893.
Many labor and delivery wards have implemented continuous fetal and maternal monitoring to improve patient safety, but this continuous monitoring may also have unintended consequences, such as alarm fatigue. This labor and delivery ward sought to decrease the overuse of monitoring, and related false or missed alarms, on low-risk obstetrical patients. Through the development and implementation of a vital sign guideline assessment, the rate of alarms was decreased with no increase in maternal complications.
Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.
Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.
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. 

Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;31:716-724.
Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.
Bernstein SL, Catchpole K, Kelechi TJ, et al. Jt Comm J Qual Patient Saf. 2022;48:309-318.
Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.
Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326:1207-1208.
Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.
Shah SN, Amato MG, Garlo KG, et al. J Am Med Inform Assoc. 2021;28:1081-1087.
Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. Over a one-year period, this study found that medication-related CDS alerts associated with renal insufficiency were nearly always deemed inappropriate and were all overridden. These findings highlight the need for improvements in alert design, implementation, and monitoring of alert performance to ensure alerts are patient-specific and clinically appropriate.  
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17:8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
Alshahrani F, Marriott JF, Cox AR. Int J Clin Pharm. 2020;43:884-892.
Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.
Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38:1072-1076.
In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.
Co Z, Holmgren AJ, Classen DC, et al. J Am Med Inform Assoc. 2020;27:1252-1258.
Using data from the Computerized Physician Order Entry (CPOE) Evaluation Tool, this study compared hospital performance against fatal orders and nuisance orders. From 2017 to 2018, overall performance increased and fatal order performance improved slightly; there was no significant change in nuisance order performance; however, these results indicate that fatal alerts are not being prioritized and that over-alerting in some cases may be contributing to alert fatigue.