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.
Thiele L, Flabouris A, Thompson C. PLoS ONE. 2022;17:e0269921.
Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.
Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32:184-189.
Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.
Hibbert PD, Molloy CJ, Hooper TD, et al. Int J Qual Health Care. 2016;28:640-649.
The Institute for Healthcare Improvement's Global Trigger Tool is widely used to identify adverse events. This systematic review found variation in how the tool is implemented, with differing rates of adverse events detected. The authors suggest modifying the trigger tool to capture errors of omission and to assess the preventability of events identified.
Magrabi F, Liaw ST, Arachi D, et al. BMJ Qual Saf. 2016;25:870-880.
… BMJ Qual Saf … BMJ Qual Saf … This analysis of data from a voluntary reporting system characterizes the types of … subject of a recent book . … Magrabi F, Liaw ST, Arachi D, RuncimanW, Coiera E, Kidd MR. Identifying patient safety problems …
Callen J, Giardina TD, Singh H, et al. J Med Internet Res. 2015;17:e60.
Providing test results directly to patients is one way in which enhanced patient engagement could improve safety, as failure to appropriately follow up on test results is a recognized cause of diagnostic errors. Accomplishing this will require endorsement from physicians, and this survey examines the attitudes of Australian emergency physicians regarding direct provision of test results to patients. The majority of physicians expressed discomfort with patients having direct access to test results, mainly because physicians feared patients would experience undue anxiety or lack the knowledge necessary to interpret the results. More physicians supported providing patients with direct access to normal test results than abnormal test results, mirroring the findings of a prior survey of primary care providers. Physicians were more supportive of direct release of test results if it would decrease their own workload. The results of this survey reveal the need for careful exploration of the best methods to increase patient engagement without disregarding clinicians' concerns. A previous AHRQ WebM&M interview with Dave deBronkart discussed allowing patients to access their medical records.
Magrabi F, Baker M, Sinha I, et al. Int J Med Inform. 2015;84:198-206.
Health information technology can both improve patient safety and introduce risks. This analysis examined all safety events associated with the United Kingdom's national program for health information technology. The researchers found that while most events were technical failures, incidents involving human errors had a higher chance of causing harm to patients. Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely to impact care delivery. These results underscore the concerns in prior reports about the unintended consequences of implementing health information technology on patient safety. The findings also lend weight to the Institute of Medicine recommendations that errors related to health information technology be reported and investigated in the United States. A past AHRQ WebM&M perspective explored the promised benefits of health information technology alongside the challenges of implementation and idiosyncrasies of available systems.
Chen J, Ou L, Hillman KM, et al. Med J Aust. 2014;201:167-70.
Although rapid response teams have been widely advocated, the evidence for their benefit remains mixed. This observational study sought to analyze the incidence of inpatient cardiopulmonary arrest and related mortality while rapid response teams were being implemented in Australia. Between 2002 and 2009, the mortality associated with inpatient cardiopulmonary arrests decreased over time. The authors found that most of the decline was due to decreased incidence of arrest, not increased survival following arrest. This finding suggests that rapid response did not play a significant role in reducing mortality from in-hospital arrest in this population, consistent with prior studies.
Magrabi F, Ong M-S, Runciman WB, et al. J Am Med Inform Assoc. 2012;19:45-53.
This study reviewed nearly 900,000 reports from the FDA Manufacturer and User Facility Device Experience database (MAUDE) and identified 678 reports describing health information technology issues. Investigators uncovered problems with software functionality, system configuration, interface with devices, and network configuration as new categories to the existing classification system.
Westbrook JI, Reckmann MH, Li L, et al. PLoS Med. 2012;9:e1001164.
Although computerized provider order entry (CPOE) systems are being more widely implemented and appear to reduce medication errors, little data exists on the effectiveness of specific CPOE systems. This study evaluated the implementation of two widely used off-the-shelf CPOE systems (with limited decision support) and found that both resulted in significant reductions in serious medication errors. The article also details types of new errors induced by CPOE systems, which, while common, were generally not clinically significant. As the evidence base around implementation of CPOE systems remains relatively small, studies like this that evaluate the real-world performance of information technology are increasingly important.
… Proc. 2011;19-1667. … Bozzo Silva PA … J. … V. … KF … B. … VL … TJ … R. … I. … D. … EV … E. … TR … J. … JR … BW … … … L. … X. … RB … CA … G. … M. … O. … C. … Y. … M. … TC … A. … MM … M. … C. … P. … W. … S. … N. … G. … HR … CG … CP … JH … F. … MS … W. … E. … …
Pham JC, Gianci S, Battles J, et al. Qual Saf Health Care. 2010;19:446-51.
… available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This … group of error reporting experts in order to develop a learning community for incident reporting. The ultimate …
… Care . 2010;19(suppl 2):i1-i47. … Greaves FEC; Bin Khalid A; Stanton EAI … R. … OT … M. … D. … M. … B. … C. … ME … T. … N. … A. … R. … C. … C. … J. … M. … S. … … … Jean-Baptiste … Poon … Ruelas … Donaldson … Newton … Runciman … Free … Fahlgren … Akiyama … Farlow … Yaron … Locke …
Flabouris A, Chen J, Hillman K, et al. Resuscitation. 2010;81:25-30.
Nearly all of the calls to a rapid response team in this large Australian study required critical care interventions such as airway management or use of inotropic drugs. Calls were also significantly more common during morning hours.