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.
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;329:1149-1150.
The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.
Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.
… to communicate important information which introduces a patient safety risk . One healthcare system searched … D, Hallisey RK, et al. Improving allergy documentation: a retrospective electronic health record system-wide patient …
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55:43-103.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications.
In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.
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.
Gupta A, Quinn M, Saint S, et al. Diagnosis (Berl). 2021;8:167-175.
… Diagnosis (Berl) … This article describes the use of a case-based simulation to explore how physicians reason, … and employed debiasing strategies . … Gupta A, Quinn M, Saint S, et al. How physicians think: a case-based …
This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.
Mello MM, Roche S, Greenberg Y, et al. BMJ Qual Saf. 2020;29:895-904.
… institutional leadership support including oversight by a full-time project manager, investments in physician … MM, Roche S, Greenberg Y, Folcarelli PH, Van Niel MB, KachaliaA. Ensuring successful implementation of …
Greene MT, Gilmartin HM, Saint S. Am J Infect Control. 2020;48:2-6.
This cross-sectional study reports the results of an ongoing national survey of infection preventionists to assess hospital infection control program characteristics and organizational practices to prevent common healthcare-associated infections. One-third of responding hospitals reported characteristics of organizational safety culture (e.g. employee perceptions of feeling safe to speak up, ask for help, or provide feedback), which was associated with increased odds of using some recommended practices for preventing catheter-associated urinary tract infections and ventilator-associated pneumonia.
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
Mendu ML, Lu Y, Petersen A, et al. BMJ Qual Saf. 2020;29.
This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.
Quinn M, Forman J, Harrod M, et al. Diagnosis (Berl). 2019;6:241-248.
… communication between learners and their supervisors. A team of social scientists and clinicians conducted an … for more clinician- and patient-centered technical tools. A WebM&M commentary discussed a diagnostic error involving learners …
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
… Patient Saf … Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project … safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured …