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.
Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.
Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.
Previous research has identified gender and racial disparities in the burden of diagnostic errors. In this study, researchers conducted a series of human-centered design workshops with a diverse set of stakeholders who generated a set of design challenges, principles, and solutions for addressing diagnostic disparities, improving healthcare quality, and promoting equity and inclusion of marginalized patients. Participants also identified two prototypes for the solutions – a visit preparation guide to teach patients how to advocate for themselves and a tool for identifying patients who may be at increased risk for experiencing a diagnostic error.
Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.
Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.
Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2022;57:654-667.
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.
Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2022;64:6-20.
… Hum Factors … Safe diagnosis is a complex challenge requiring multidisciplinary approaches . … and improve patient outcomes. … Yousef EA, Sutcliffe KM, McDonald KM, et al. Crossing academic boundaries for …
Connors C, Dukhanin V, Norvell M, et al. J Healthc Manag. 2021;66:19-32.
The Resilience in Stressful Events (RISE) program provides peer support for healthcare workers who are involved in an adverse event. RISE program volunteers surveyed in this study reported positive perceptions of program participation and personal empowerment.
Connors C, Dukhanin V, March AL, et al. J Patient Saf Risk Manag. 2019;25:22-28.
Adverse events can have significant psychological impacts on the providers involved and involvement in medical errors can increase risk of burnout among second victims. This study describes the nurse utilization of the Resilience in Stressful Events (RISE) peer support program. The authors found high awareness of the program among nurses, but low utilization. Nurses who had used the program reported greater resilience, but more burnout than those who had not.
Dukhanin V, Edrees HH, Connors CA, et al. J Pediatr Nurs. 2018.
… and reduced job satisfaction. Researchers evaluated a second victim support program for nurses and found the initiative to be well-liked and effective in promoting a more robust culture of safety . …
Sarkar U, McDonald KM, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.
… safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the … opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors …
Tedesco D, Asch SM, Curtin C, et al. Health Aff (Millwood). 2017;36:1748-1753.
… overall increase in opioid-related hospital visits, with a peak in 2010 and gradual decline since then. Coincident with the decline in opioid-related visits, a sharp rise in heroin-related hospital visits emerged. These …
McDonald KM, Su G, Lisker S, et al. Implement Sci. 2017;12:79.
Diagnostic error in the ambulatory care setting is common, particularly with regard to missed or delayed diagnoses of cancer. This study used human factors engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor patients with high-risk conditions and to identify vulnerabilities in the monitoring process that could lead to delayed diagnoses.
Moghavem N, McDonald KM, Ratliff JK, et al. Med Care. 2016;54:359-64.
The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. This study demonstrated that PSIs were associated with longer hospital stays and increased mortality. Neurosurgery patients were more likely to have PSIs occur than other surgical patients.
Davies SM, Saynina O, Baker LC, et al. Am J Med Qual. 2015;30:114-8.
The AHRQ Patient Safety Indicators (PSIs) do not include adverse events after hospital discharge, which could introduce bias into measurement of safety events at the individual hospital level. However, this study found that inclusion of postdischarge adverse events in PSI calculations did not significantly change comparisons of safety between hospitals or within the same hospital over time.
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Ann Plast Surg. 2015;74:597-602.
Using AHRQ patient safety indicators, this study established that approximately 4% of plastic surgery patients experience an adverse event during their hospital stay. This rate is relatively low compared with other surgical disciplines, but it is significant due to the proportion of young healthy patients who undergo plastic surgery.
McDonald KM, Bryce CL, Graber ML. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39.
… to help patients prevent diagnostic errors, including a list of questions to ask their provider. These approaches … . The article also argues for the role of patients as a "crucial voice" in augmenting diagnostic delivery systems, research, and policy. A previous AHRQ WebM&M perspective with Dr. Mark Graber discussed diagnostic …
Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Ann Intern Med. 2013;158:426-32.
… Med … Simulation was initially used in health care as a tool for teaching clinical skills, but it is increasingly being used as a component of teamwork training . Although a recent … in the Annals of Internal Medicine . An AHRQ WebM&M perspective and interview discuss the role of technology in …