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.
Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.
Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26:251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.
Ottosen MJ, Sedlock E, Aigbe AO, et al. J Patient Saf. 2021;17:e1145-e1151.
This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.
Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2022;105:1561-1570.
In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
… J Patient Saf Risk Manag … The July effect is a phenomenon … these practitioners to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July effect. J Patient Saf Risk Manag. 2021;26(3):93-96. …
Schulz-Moore JS, Bismark M, Jenkinson C, et al. Jt Comm J Qual Patient Saf. 2021;47:376-384.
… Jt Comm J Qual Patient Saf … Error disclosure is critical to … injury, and patient characteristics. … Schulz-Moore JS, Bismark M, Jenkinson C, et al. Assessing patients 2019 … item generation for a novel survey questionnaire. Jt Comm J Qual Patient Saf. Epub 2021 Apr 11. …
… J Patient Saf … Unanticipated adverse events harm not only … to the use of organization support programs. … Edrees HH, Wu AW. Does one size fit all? Assessing the need for organizational second victim support programs. J Patient Saf. 2021;17(3):e247-e254. …
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
The COVID-19 pandemic has generated numerous concerns in the healthcare industry, one of which is the potential for significant malpractice claims. This article discusses the possibility of a medical malpractice crisis in response to poor outcomes associated with COVID-19 and suggests that the industry follow an alternate path away from tort reform and legal actions. Alternatives such as communication and resolution programs can focus on patient safety principles such as transparency, redesign of systems to reduce adverse events, and patient and family support that could prevent traditional legal actions.