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.
Adams M, Hartley J, Sanford N, et al. BMC Health Serv Res. 2023;23:285.
Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.
Pavithra A, Mannion R, Sunderland N, et al. J Health Org Manag. 2022;36:245-271.
Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.
Abrams R, Conolly A, Rowland E, et al. J Adv Nurs. 2023;79:2189-2199.
Speaking up about safety concerns is an important component of safety culture. In this study, nurses in a variety of fields shared their experiences with speaking up during the COVID-19 pandemic. Three themes emerged: the ability to speak up or not, anticipated consequences of speaking up, and responses, or lack thereof, from managers.
Bion J, Aldridge CP, Girling AJ, et al. BMJ Qual Saf. 2021;30:536-546.
In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.
Blenkinsopp J, Snowden N, Mannion R, et al. J Health Org Manag. 2019;33:737-756.
Staff willingness to report threats to patient safety is critical to preventing errors and improving safety and is an indicator of an organization’s safety culture. The authors discuss studies exploring what factors influence whistleblowing, organizational responses, and implications for practice or policy. The authors concluded that the existing literature focuses on the decision to speak up. There is limited evidence discussing organizational responses or systems-level changes, yet these actions influence whether the patient safety threats are addressed and if future events will be reported.
Psychological safety empowers staff to speak up about problems. This commentary highlights how senior managers can help ensure that departmental-level conditions facilitate the reporting of concerns. The authors call for organizations and managers to encourage speaking up and to respond appropriately.
Mannion R, Davies H, Powell M, et al. J Health Organ Manag. 2019;33:221-240.
Organizational acceptance of accountability for failures and implementation of solutions are critical to improve safety. This review explores the impact of investigations focused at the individual, practice, and system levels. The authors describe design and operational failings at each level that enable purposeful or accidental patient harm.
Mannion R, Braithwaite J. Int J Health Policy Manag. 2017;6.
Patient safety has been a persistent goal in health care for nearly two decades, but reductions in preventable patient harm remain challenging to sustain. This commentary explores limitations in current system-focused approaches to improvements and advocates for deeper exploration and adoption of strategies that recognize the complexity of the health care environment.
Aldridge C, Bion J, Boyal A, et al. Lancet. 2016;388:178-86.
In-hospital mortality for many conditions is higher on the weekends than on weekdays—a phenomenon known as the weekend effect. Some hypothesize lower specialty physician staffing levels on weekends explains the mortality difference. This cross-sectional study compared specialist staffing levels and mortality rates at 115 hospitals in the English National Health Service on Sundays compared to Wednesdays. Researchers found a higher mortality rate and lower intensity of specialty services on weekends, but there was no correlation between the two ratios. Although this study is not definitive, it does imply that alternate mechanisms may explain the weekend effect, such as case mix differences, variation in nonphysician staffing, or lower availability of diagnostic services. A previous PSNet interview discussed the weekend effect in health care.
Jones A, Lankshear A, Kelly D. Int J Nurs Stud. 2016;59:169-76.
Nurse leaders play a key role in patient safety. This interview study found that nurse executives advocate for quality and safety with executive boards by building relationships with board colleagues and presenting the rationale for quality and safety practices. The authors conclude the nurse perspectives are critical to providing insights about quality and safety actions to hospital boards.
Simon M, Maben J, Murrells T, et al. J Health Serv Res Policy. 2016;21:147-55.
This study expands on analyses and conclusions from published findings exploring the effects of moving to a new hospital with 100% single room accommodations. The researchers used nonequivalent controls by comparing results to a hospital that had not changed buildings but planned to do so (steady state control) and a hospital that moved to a new building with fewer than 50% single rooms (new build control). Falls, pressure ulcers, and Clostridium difficile infections increased in the older patients' ward after the move to single rooms. However, there was also a significant change in the case mix on this ward following the move, which may have explained these changes in adverse events. On the acute assessment unit, falls and medication errors temporarily increased for the first 6 months but then returned to prior rates. The authors found neither clear evidence of benefit nor increased risk of harm attributable to moving to all single room accommodations.
Williams H, Edwards A, Hibbert P, et al. Br J Gen Pract. 2015;65:e829-e837.
Adverse events after hospital discharge are common, affecting nearly 20% of patients within 3 weeks of discharge. This study used data from the United Kingdom's National Reporting and Learning System to analyze the contributors to these adverse events. Principal contributing factors included inadequate discharge communication between hospital-based and outpatient physicians and insufficient assessment of patients' need for community-based services.
Maben J, Griffiths P, Penfold C, et al. BMJ Qual Saf. 2016;25:241-56.
This study used robust research methods to examine the expected and unanticipated effects of moving to all single-occupancy inpatient rooms. The accompanying editorial points out that on the surface this seems like a common sense intervention likely to improve patient experience and safety. However, this study demonstrates the complex effects even seemingly straightforward interventions can create. Although two-thirds of patients preferred the single rooms, some patients felt more isolated and lonely. Staff expressed concerns about worsened visibility, surveillance, teamwork, and monitoring. In addition, staff workflows had to change significantly and their hourly walking distances increased substantially. There was no evidence that single rooms reduced infections. Although fall rates increased following the move, the researchers felt that based on the patterns and comparison to the control hospital, this may not have been attributable to the single rooms. As the editorial highlights, this study supports the importance of vigorously evaluating a range of impact measures, including quality, safety, costs, and staff and patient experiences.
Kringos DS, Suñol R, Wagner C, et al. BMC Health Serv Res. 2015;15:277.
The variable success of patient safety interventions has been attributed to the context in which these strategies have been implemented. In this systematic review, researchers found that contextual aspects that influence success of interventions are not systematically examined or reported, hindering understanding of how context affects implementation of patient safety efforts.
Millar R, Freeman T, Mannion R. BMC Health Serv Res. 2015;15:196.
This qualitative study examined mechanisms by which hospital boards could provide more effective oversight of quality and safety activities. Trust among organizational leadership and prioritization of data analysis emerged as important methods by which boards could help improve safety.
Mannion R, Thompson C. Int J Qual Health Care. 2014;26:606-12.
Cognitive approaches to patient safety have mostly focused on individual decisions. This study instead examines group decision-making and its safety implications. The authors describe four pitfalls associated with group decisions: groupthink in which the strongly connected mentality of members hinders dissenting opinion; social loafing in which people expend less effort because of a perceived failure to obtain individual credit for efforts; group polarization in which individual moderate positions are subsumed by more extreme or effort intensive group decisions; and escalation of commitment in which a poor outcome following a significant investment results in further commitment of resources instead of exploring a new approach. These four concepts can serve as a theoretical framework for future empiric work to characterize and improve group decision-making as an aspect of safety culture.
This commentary explores the differences between individuals failing to raise concerns and organizations disregarding problems that have been reported. Several organizational failures in the National Health Service provide context for this comparison and illustrate the need to build systems that reliably record and respond to shortcomings raised by staff.
Hospital leadership oversight is thought to be critical for advancing patient safety initiatives. This narrative review synthesized 122 studies examining the role of hospital board oversight in fostering safety practices. Investigators found that high-performing hospitals are more likely to have skilled board members and standardized board processes compared with low-performing hospitals, highlighting the value of effective and committed leadership that prioritizes quality and safety improvement. However, more research is needed to determine optimal hospital governance. A past AHRQ WebM&M interview discussed the role of leadership and medical administration in patient safety.