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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 2265 Results
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Chew MM, Rivas S, Chesser M, et al. J Patient Saf. 2023;19:23-28.
Provision of enteral nutrition (EN) is a specialized process requiring careful interdisciplinary teamwork. After discovering significant issues with ordering, administration, and documentation of EN, this health system updated its workflows to improve safety. EN therapies were added to the electronic medication administration record (MAR) and the barcoding system was updated. After one year, all EN orders were barcode scanned and nearly all were documented as given or included a reason why they were not given.
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2022;Epub Dec 5.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2022;Epub Nov 16.
Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.
Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.
Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.
Dixit RA, Boxley CL, Samuel S, et al. J Patient Saf. 2023;19:e25-e30.
Electronic health records (EHR) may have unintended negative consequences on patient safety. This review identified 11 articles focused on the relationship between EHR use and diagnostic error. EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation and communication. The majority of issues were a related to providers’ cognitive processing, revealing an important area of research and quality improvement.
Maul J, Straub J. Healthcare (Basel). 2022;10:2440.
Patient misidentification can lead to serious medical errors and patient harm. This article provides an overview of how artificial intelligence (AI) frameworks can be combined with patient vital sign data to prevent patient misidentification. The authors suggest that this system could provide alerts indicating possible misidentification or it could be paired with other indicator systems as part of a multi-factor misidentification system.
Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.
Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.
Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.
Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.

Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.
Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.
Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.
Erstad BL, Romero AV, Barletta JF. Am J Health Syst Pharm. 2023;80:87-91.
Weight-based dosing is vulnerable to error due to inaccurate estimation of body weight, use of metric vs. non-metric units, or patients being underweight or overweight. This commentary suggests strategies for reducing weight- and size-based dosing errors including reduction in reliance on estimated body weight, standardizing descriptor (e.g., body mass index), limiting options in the electronic health record (EHR), and integrating complex calculations into the EHR.
Apathy NC, Howe JL, Krevat SA, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.
Alqahtani N. J Eval Clin Pract. 2022;28:1037-1049.
Insulin-related errors result in nearly 100,000 emergency department visits annually in the United States, with 30% resulting in hospitalization. It is unclear if published guidelines and strategies for reducing these errors have been effective; therefore, this review sought to identify interventions to reduce insulin errors in home and hospital settings. Three themes emerged: technology, education, and policy. Understanding these findings may help clinicians and patients to decrease insulin administration errors and help researchers develop and evaluate future studies targeting insulin-related errors.

Washington DC; Office of Senator Mark Warner: November 25, 2022.

There is lack of consensus concerning the need for increased system and policy attention on cybersecurity challenges as a threat to patient safety. The report suggests modifications within the federal government infrastructure to increase attention to cybersecurity as a safety issue, public/private partnership opportunities, and policy development to reduce the potential for cyberattacks that impact care delivery.
Patient Safety Primer December 14, 2022

The rapid expansion of telehealth and the variation in implementation of new models of care into medical practice has resulted in emerging concerns regarding patient safety. This primer summarizes these concerns – including diagnostic errors, medication errors, and health equity considerations – as well as telehealth implementation strategies to enhance patient safety.

Boxley C, Krevat SA, Sengupta S, et al. J Patient Saf. 2022;18:e1196-e1202.
COVID-19 changed the way care is delivered to hospitalized patients and resulted in new categories and themes in patient safety reporting. This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors, pressure ulcers, and falls.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).