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 - 18 of 18 Results

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

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Ruppel H, Dougherty M, Bonafide CP, et al. BMJ Open Qual. 2023;12:e002342.

Alarm fatigue can lead to desensitization to safety alerts and threaten patient safety. In this survey of 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation where an alarm went unchecked despite a patient requiring urgent attention. The researchers found that alarm burden was more common among respondents who rated their hospital’s safety as poor or reported poor work environments.

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose.

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WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century.

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Webster CS, Mahajan R, Weller JM. Br J Anaesth. 2023;131:397-406.

Systems involving people, tools, technology, and work environments must interact effectively to ensure the delivery of safe, effective care. This narrative review uses a sociotechnical perspective to explore the inter-relationship between technology and the human work environment during the delivery of anesthesia in the operating room. The authors discuss systems-level approaches, such as such as surgical safety checklists, as well as the role of resilience and new technologies (i.e., artificial intelligence).

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

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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.

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

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

Technology as a Tool for Improving Patient Safety

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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.

Curated Libraries

Medication/Drug Errors

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...

Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.

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WebM&M Case November 30, 2021

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

Emergency department monitor alarms rarely change clinical management: an observational study.

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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.

Lessons learned from medical malpractice claims involving critical care nurses.

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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.

Complications of ECMO During Transport

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WebM&M Case April 29, 2020

A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed.

Team-based intervention to reduce the impact of nonactionable alarms in an adult intensive care unit.

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Yeh J, Wilson R, Young L, et al. J Nurs Care Qual. 2019;35:115-122.

Prior research has found that nonactionable alarms are common and contribute to alarm fatigue among providers in intensive care units. This single center study employed an interprofessional team-based approach to adjust the default thresholds for arrhythmias and specific parameters such as oxygen saturation, which resulted in a nearly 47% reduction in nonactionable alarms over a two-week period.

A piece of my mind. Hard times and hard stops.

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Lifflander AL. JAMA. 2019;321:837-838.

Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward.

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Buckley MS, Rasmussen JR, Bikin DS, et al. Ther Adv Drug Saf. 2018;9:207-217.

This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.

Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit.

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Balasuriya L, Vyles D, Bakerman P, et al. J Patient Saf. 2017;13:144-148.

This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue.

Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.

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Drew BJ, Harris P, Zègre-Hemsey JK, et al. PLoS One. 2014;9:e110274.

Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

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Carspecken W, Sharek PJ, Longhurst CA, et al. Pediatrics. 2013;131:e1970-e1973.

This commentary describes an incident involving an inappropriate override of a drug allergy alert and details changes the hospital made in its medication allergy alert system in response to the event.

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

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Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-83.

Computerized provider order entry (CPOE) systems prevent prescribing errors by warning clinicians about medication interactions or contraindications. However, extensive research has shown that clinicians ignore many warnings, especially those perceived as clinically inconsequential. In this randomized trial, investigators created a "hard stop" warning that essentially prevented co-prescribing of warfarin and trimethoprim-sulfamethoxazole (a combination that exposes patients to severe bleeding risks). Although the hard stop was much more successful than a less stringent warning at preventing co-prescribing, the trial was stopped and the warning abandoned because several patients experienced delays in needed treatment with one of the drugs. The accompanying editorial by Dr. David Bates points out that this study vividly illustrates the unintended consequences of CPOE, a persistent issue that has slowed the pace of CPOE implementation.

On the Other Hand

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WebM&M Case May 1, 2007

A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.

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