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.
Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.
Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.
Reader TW, Gillespie A. J Appl Psychol. 2021;106:439-451.
Patients and family members provide valuable insights for investigating patient safety events in hospitals. This study found that patient-generated information on patient safety risks during hospitalization (derived from evaluations of care and healthcare complaints) may differ from staff-generated information (derived from staff surveys and incident reports), and suggests that health systems engage patients and families in order to improve safety.
van Dael J, Reader TW, Gillespie A, et al. BMJ Qual Saf. 2020;29:684-695.
This article reviewed 74 academic and 10 policy resources, as well as interviewed 13 experts, to understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. Findings highlight the need for standardized methods to use and report complaints data, novel policy strategies, and analysis strategies to generate actionable learning insights and translation into quality improvement by affecting leadership and safety culture are discussed.
Noort MC, Reader TW, Gillespie A. Front Psychol. 2019;10:668.
This psychological experiment sought to measure speaking-up behaviors of medical students and the general public, using a masked experiment rather than asking participants to report their behaviors or comfort level. Investigators found that though participants were more likely to speak up when they received specific information about safety risks in an experimental situation, many still chose to remain silent about unsafe conditions. They also found differences in participants' reported willingness to speak up compared to their observed behavior, suggesting that behavioral experiments are important to enhance speaking up for safety.
Gillespie A, Reader TW. Milbank Q. 2018;96:530-567.
Patient voices provide crucial insight into health care safety hazards. Researchers classified 1110 patient complaints submitted to England's National Health Service to identify stages of care where harm occurred. The most common cause of major or catastrophic harm was diagnostic error.
Gillespie A, Reader TW. BMJ Qual Saf. 2016;25:937-946.
This study describes the development and validity testing of a new tool for coding and measuring the severity of patient complaints. Application of this framework could help health care organizations appropriately monitor and learn from insights from patient reports.
Kapur N, Parand A, Soukup T, et al. JRSM Open. 2016;7:2054270415616548.
Applying aviation safety methods in health care settings has received mixed levels of acceptance as a useful approach. This review compares characteristics of aviation and health care, suggests that organizations should consider unique aspects in medicine when developing aviation-based strategies, and notes the benefits of aviation's focus on human factors, teamwork training, and culture to enhance safety.
Reader TW, Gillespie A, Roberts J. BMJ Qual Saf. 2014;23:678-689.
Patient complaints may help identify complications during hospitalization. For example, the official investigation of the Mid-Staffordshire NHS Foundation Trust in the United Kingdom found that unsolicited written patient complaints had identified many areas of poor care that likely contributed to preventable patient deaths. This systematic review sought to create a common taxonomy for patient complaints in order to standardize future research and analyses. The taxonomy includes three main domains—clinical, management, and relationships—which are parsed into seven categories and further sub-categories. This taxonomy may enable comparisons between health care institutions and more sophisticated aggregate analyses of patient complaints, which in turn could contribute to better understanding about the value of patient complaints and the effectiveness of different interventions aimed at addressing patient concerns.
Reader TW, Flin R, Mearns K, et al. BMJ Qual Saf. 2011;20:1035-42.
Situational awareness refers to the degree to which perception matches reality. This study assessed situational awareness of intensive care unit teams through direct observation of team rounds and assessment of the degree to which team members were able to anticipate clinical deterioration.