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.
Wilson C, Janes G, Lawton R, et al. BMJ Qual Saf. 2023;32:573-588.
Feedback interventions (e.g., debriefing, peer-to-peer, audit, and feedback) can encourage learning from safety events and improve quality of care. This systematic review of 48 studies found that providing feedback to emergency medical services (EMS) personnel can improve documentation and adherence to protocols, with some studies also documenting improvements in clinical decision-making and cardiac arrest performance.
Albutt AK, Ramsey L, Fylan B, et al. Health Expect. 2023;26:1467-1477.
Patients' healthcare-seeking behaviors changed during the COVID-19 pandemic, particularly during the first wave. This longitudinal study sought patient perspectives about their experiences accessing healthcare, activities they undertook to keep themselves and others safe, and their understanding of healthcare system resilience and resources. Three themes emerged: a "new safety normal," existing vulnerabilities and heightened safety, and "are we all in this together?" The study highlighted that preexisting gaps in care experienced by those with chronic conditions or other vulnerabilities widened during the pandemic and deserve further research.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.
Patient and caregiver engagement in medical treatment can promote safety. This scoping review explored the qualitive research regarding how patients and caregivers engage in safety during cancer treatment. Four themes were identified – patient perception and involvement in safety; patient engagement in their care; safety as a collective responsibility; and the importance of caregivers relative to the amount of support they receive.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
Harrison R, Johnson J, Mcmullan RD, et al. J Patient Saf. 2022;18:587-604.
… J Patient Saf … Providers who are involved in a medial error … increase providers’ coping skills. … Harrison R, Johnson J, McMullan RD, et al. Toward constructive change after … theory as a psychosocial model for clinician recovery. J Patient Saf. Epub 2022 May 25. …
Wailling J, Kooijman A, Hughes J, et al. Health Expect. 2022;25:1192-1199.
Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.
Ramsey L, Albutt AK, Perfetto K, et al. Int J Equity Health. 2022;21:13.
… Int J Equity Health … Patients with learning disabilities … individualized care and communication needs. … Ramsey L, Albutt A, Perfetto K, et al. Systemic safety inequities for people with learning …
Cribb A, O'Hara JK, Waring J. BMJ Qual Saf. 2022;31:327-330.
Patient safety advocates recommend a shift from a blame culture to a just culture. This commentary describes three types of justice that exist in healthcare - retributive, no blame or qualified blame, and restorative. The authors invite debate around the concept of just culture and its role in the “real world”.
Prior research found that patients with learning disabilities (e.g., autism, attention deficit disorder, Down’s syndrome) face numerous patient safety threats. In this narrative review, the authors synthesized academic and grey literature exploring patient safety outcomes for individuals with learning disabilities in acute care settings. Findings suggest that individuals with learning disabilities experience poorer patient outcomes but that increasing family and caregiver engagement as well as provider understanding of the needs of people with learning disabilities can improve outcomes.
Janes G, Harrison R, Johnson J, et al. J Eval Clin Pract. 2022;28:315-323.
… J Eval Clin Pract … Many organizations have implemented … interventions. … Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: Health … designed to help them prepare for coping with error. J Eval Clin Pract. Epub 2021 Mar 6. doi: 10.1111/jep.13555. …
Albutt AK, Berzins K, Louch G, et al. nt J Ment Health Nurs. 2021;30:798-810.
The UK’s National Health System has faced gaps in mental health care delivery affecting patient safety. Interviews with 14 mental health professionals identified several factors associated with patient safety in mental health service settings including safety culture, communication systems, service user factors, service process, and staff workload. Interventions to improve patient safety in mental health settings should be developed with these factors in mind.
The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23:549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.
McHugh SK, Lawton R, O'Hara JK, et al. BMJ Qual Saf. 2020;29:672-683.
Team reflexivity represents the way individuals and team members collectively reflect on actions and behaviors, and the context in which these actions occur. This systematic review identified 15 studies describing the use of team reflexivity within healthcare teams. Included interventions, most commonly simulation training and video-reflexive ethnography, focused on the use of reflexivity to improve teamwork and communication. However, methodological limitations of included studies precluded the authors from drawing conclusions around the impact of team reflexivity alone on teamwork and communication.
Baxter R, Taylor N, Kellar I, et al. BMJ Qual Saf. 2019;28:618-626.
This qualitative study compared four high-performing geriatric inpatient units with four average-performance units in order to understand factors that contribute to high performance. The authors conclude that the safety practices did not differ between the high versus average performers. Instead, optimal teamwork and positive safety culture led the high-performing wards to implement these safety practices in a more effective way.
Harrison R, Sharma A, Lawton R, et al. J Patient Saf. 2021;17:e1633-e1637.
Mentors can serve as coaches to help improve clinician performance. This study examined whether having a professional mentor affected physicians' involvement in an adverse event or near miss. In an online survey, 85% of physicians reported involvement in either an adverse event or near miss, and nearly half described having a mentor. Physicians with mentors were about 10% less likely to be involved in adverse events or near misses, across differing levels of harm. The authors conclude that mentoring for physicians may reduce preventable harm but suggest that further research is needed to determine the elements of mentorship that improve safety outcomes. In a past PSNet interview, Hardeep Singh touched on the importance of mentorship in supporting patient safety researchers.
Lawton R, Robinson O, Harrison R, et al. BMJ Qual Saf. 2019;28:382-388.
Risk aversion in clinical practice may lead to the ordering of unnecessary tests and procedures, a form of overuse that may pose harm to patients. Experienced clinicians may be more comfortable with uncertainty and risk than less experienced providers. In this cross-sectional study, researchers surveyed doctors working in three emergency departments to understand their level of experience and used vignettes to characterize their reactions to uncertainty and risk. They found a significant association between more clinical experience and less risk aversion as well as a significant association between more experience and greater ease with uncertainty. The authors caution that they cannot draw conclusions on how these findings impact patient safety. An accompanying editorial suggests that feedback is an important mechanism for improving confidence in clinical decision-making. A WebM&M commentary discussed risks related to overdiagnosis and medical overuse.
O'Hara JK, Aase K, Waring J. BMJ Qual Saf. 2019;28:3-6.
Various conditions must be in place to fully enable patient engagement. This commentary suggests that systems and care teams establish adaptable conditions to facilitate communication with patients during care activities to contribute to system resilience and health care safety.