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.
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197:1389-1395.
This commentary explores the results of a multidisciplinary discussion on the intersection of "respect" and "dignity" as requirements of safe care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, which include the need to expand the research on respect in the intensive care unit and the value of responding to failures of respect as safety incidents to design mechanisms for improvement.
The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.
Tothy AS, Limper HM, Driscoll J, et al. Jt Comm J Qual Patient Saf. 2016;42:281-5.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Judson TJ, Howell MD, Guglielmi C, et al. Jt Comm J Qual Patient Saf. 2013;39:468-474.
Case duration and the number of providers involved in a given operation were independent risk factors for retained surgical items, according to this prospective cohort study of nearly 24,000 procedures at a single academic institution.
Howell MD, Ngo L, Folcarelli P, et al. Crit Care Med. 2012;40:2562-8.
A rapid response team model that relied on clinical triggers to summon the primary team caring for the patient—rather than a dedicated, separate team—resulted in sustained reductions in unexpected inpatient mortality over a 4-year period.