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Ostrow O, Prodanuk M, Foong Y, et al. Pediatrics. 2022;150:e2021055866.
Appropriate antibiotic prescribing is a core component of antibiotic stewardship programs to reduce the risk of antibiotic-resistant microbes. This study assessed the rate of misdiagnosed pediatric urinary tract infections (UTI) and associated antibiotic use following implementation of a quality improvement intervention. Using three interventions (diagnostic algorithm, callback system, standardized discharge antibiotic prescription), misdiagnosis of UTI decreased by half, and 2,128 antibiotic days were saved.
Blythe R, Parsons R, White NM, et al. BMJ Qual Saf. 2022;Epub Jun 22.
Early recognition of clinical deterioration in patients is often difficult to detect and often results in poor patient outcomes. This scoping review focused on the delivery and response to deterioration alerts and their impact on patient outcomes. Only four out of 18 studies included in the review reported statistically significant improvements in at least two patient outcomes, Authors suggest that workflow and integration of the early warning system model’s features into the decision-making process may be helpful.
Smith K, Durant KM, Zimmerman C. Am J Health Syst Pharm. 2022;79:1198-1204.
Clinical decision support (CDS) systems built into electronic health records are designed to alert providers to potentially unsafe orders, but many alerts are ignored or overridden. This article describes the effectiveness of one hospital’s clinical decision support for high-risk medications both before and after alert improvements.
Liberman AL, Cheng NT, Friedman BW, et al. Diagnosis (Berl). 2022;9:225-235.
Missed diagnosis of stroke in emergency medicine settings is an important patient safety problem. In this study, researchers interviewed emergency medicine physicians about their perspectives on diagnostic neurology and use of clinical decision support (CDS) tools. Themes emerged related to challenges in diagnosis, neurological complaints, and challenges in diagnostic decision-making emergency medicine, more generally. Participating physicians were enthusiastic about the possibility of involving CDS tools to improve diagnosis for non-specific neurological complaints.
Hindmarsh J, Holden K. Int J Med Inform. 2022;163:104777.
Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.
Gonzalez-Smith J, Shen H, Singletary E, et al. NEJM Catalyst. 2022;3.
Clinical decision support (CDS) helps clinicians select appropriate medications, arrive at a correct diagnosis, and improve intraoperative decision making. Through interviews with health system executives, clinicians, and artificial intelligence (AI) experts, this study presents multiple perspectives on selection and adoption of AI-CDS in healthcare. Four emerging trends are presented: (1) AI must solve a priority problem; (2) the tool must be tested with the health system’s patient population; (3) it should generate a positive return on investment; and (4) it should be implemented efficiently and effectively.
Fischer H, Hahn EE, Li BH, et al. Jt Comm J Qual Patient Saf. 2022;48:222-232.
While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28:2654-2660.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78:s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Vasey B, Ursprung S, Beddoe B, et al. JAMA Netw Open. 2021;4:e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.
Chin DL, Wilson MH, Trask AS, et al. J Med Syst. 2020;44:185.
Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. The researchers describe a novel approach to using existing CDS systems to detect medication prescribing errors based on drug-drug interaction and allergy alert overrides. Dose alert overrides had high sensitivity to detect medication prescribing errors occurring in an inpatient setting.
Kuitunen SK, Niittynen I, Airaksinen M, et al. J Patient Saf. 2021;17:e1669-e1680.
The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
Classen DC, Holmgren AJ, Co Z, et al. JAMA Netw Open. 2020;3.
Researchers measured the safety performance of electronic health record (EHR) systems using simulated medication orders that can lead to adverse events or death in order to evaluate how well the systems identified these errors, and the mitigating effect of computerized physician order entry and clinical decision support (CDS) tools. Safety performance increased moderately over the 10-year study period but there was considerable variation in performance based on the level of decision support (basic or more complex) and EHR vendor; safety risks persist despite EHR implementation.
Vidrine R, Zackoff M, Paff Z, et al. Jt Comm J Qual Patient Saf. 2020;46:299-307.
Early recognition and treatment of sepsis is a critical safety issue. The authors of this study aimed to reduce the frequency of delayed sepsis recognition in a pediatric intensive care unit (PICU) through the use of an automated clinical decision support tool (CDS) prompting multidisciplinary sepsis huddles. After a two-year period, the average number of days between episodes of delayed sepsis recognition improved from one episode every 9 days to one every 28 days, and the median time to antibiotics decreased from 1.53 hours to 1.05 hours, representing a significant reduction.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. JMIR Med Inform. 2020;8.
Older patients are vulnerable to adverse drug events due to comorbidities and polypharmacy. This cross-sectional study from Spain reviewed prescriptions for 593 older adults aged 65-75 years with multiple comorbidities and documented polypharmacy to estimate the prevalence of potentially inappropriate prescribing using the STOPP and Beers Criteria. Potentially inappropriate prescribing was detected in over half of patients. The most frequently detected inappropriate prescriptions were for prolonged use of benzodiazepines (36% of patients) and prolonged use of proton pump inhibitors (45% of patients). Multiple risk factors associated with potentially inappropriate prescribing were identified, including polypharmacy and use of central nervous system drugs.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Rungvivatjarus T, Kuelbs CL, Miller L, et al. Jt Comm J Qual Patient Saf. 2020;46:27-36.
This study describes a multi-disciplinary quality improvement project aimed at increasing the percentage of completed medication reconciliations upon admission. Interventions included EHR workflow redesigns, provider training, and performance data reporting. After seven months, the project resulted in an increase in medication reconciliation at admission, and a higher percentage of medication reconciled across drug classes, including high-alert drugs.