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.
Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.
Patient safety efforts increasingly seek patient input and engagement to improve care. In this qualitative study, patients and families reported on recent hospitalizations and their perceptions of their care and safety. Four main themes were elicited: (1) experiences with safety problems were not unusual, (2) patients and families developed “care stories” about their experiences, (3) there was a spectrum of trust between patients and providers, and (4) having someone advocate for them was important.
… was to schedule the appointment or whether the surgeon’s office would contact her. After an 8-week delay, the … of this aggressive malignancy. … The Commentary … By SaulN. Weingart, MD, MPP, PhD, Gordon D. Schiff MD, and Ted …
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:4447-4459.
Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.
Weingart SN, Yaghi O, Barnhart L, et al. Appl Clin Inform. 2020;11.
To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography. To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:1462-1472.
Research has found that trigger tools perform poorly in cancer care. This cohort study comprised of adult patients undergoing treatment for breast, colorectal, lung or prostate cancer investigated the feasibility of a cancer-specific claims-based trigger tool to identify patients with potential adverse events. Results found that triggers affected 19% of patients during their initial year in treatment, and that trigger burden varied by disease, stage, and patient demographics. The most prevalent triggers were abnormal lab test results, blood transfusions, orders for non-contrast CT after chest radiation, and hypoxemia.
Patients and caregivers should be actively engaged in identifying and preventing patient safety events. This article describes the process of designing an app to engage patients and their caregivers in decision making that might impact safety. The authors note important themes arising from this process, including appropriate messaging for patients, creating an app promotes actions (such as suggesting questions), and presenting information accessible for a lay audience.
Holmgren J, Co Z, Newmark L, et al. BMJ Qual Saf. 2020;29:52-59.
A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.
Classen D, Li M, Miller S, et al. Health Aff (Millwood). 2018;37:1805-1812.
Most health care organizations primarily rely on retrospective techniques such as incident reporting systems to detect and respond to patient harm. Retrospective techniques do not capture a substantial proportion of patient safety events and are not effective for real-time feedback or safety incident prevention. By contrast, electronic health record–based trigger tools detect safety incidents in real time. Investigators developed and piloted the patient safety active management (PSAM) at two large community hospitals. The PSAM employed machine learning and expert clinician review of years of adverse event data to refine the Institute for Healthcare Improvement Global Trigger Tool and distilled this into a real-time risk score for patient safety incidents. The PSAM identified 10 times more safety incidents than were detected through retrospective techniques. It reliably predicted both serious adverse events and mortality. A prior PSNet perspective explored how to leverage electronic health records to enhance safety.
The Moore Foundation provides free access to this article.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
… in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change … reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings … discussed a preventable medication error at a children's hospital. …
Stockwell DC, Landrigan CP, Schuster MA, et al. Pediatr Qual Saf. 2018;3:e081.
The Centers for Medicare and Medicaid Services (CMS) has successfully reduced preventable harm from hospital-acquired conditions (HACs) through financial penalties to hospitals. Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list, raising concern about whether institutions may be neglecting other types of preventable harm. Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list. Only 58 of 240 harms were considered HACs. Some common harms identified outside the scope of HACs were intravenous catheter infiltration, surgical complications, and pain. Prior WebM&M commentaries have discussed harms from hospital-acquired infections as well as the unintended consequences of public hospital quality reporting.
This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.
Weingart SN, Zhang L, Sweeney M, et al. Lancet Oncol. 2018;19:e191-e199.
Chemotherapy errors can result in serious patient harm. This review summarized the evidence on chemotherapy errors. Most studies were performed in single-institution academic settings and few studies examined how health information technology affects patient outcomes.
D'Agostino TA, Bialer PA, Walters CB, et al. AORN J. 2017;106:295-305.
Reluctance of health care team members to speak up about safety concerns can hinder patient safety. This pre–post study of a communication training program used findings from interdisciplinary focus groups to address barriers to speaking up. The training was highly rated and authors believe it has potential to improve team communication.
Lipitz-Snyderman A, Pfister D, Classen D, et al. Cancer. 2017;123:4728-4736.
Cancer care has been the setting for seminal, practice-changing errors. This retrospective study aimed to identify adverse events in cancer care through medical record review, using a random sample of breast, colorectal, and lung cancer cases from 2012. As with prior studies, physician investigators determined preventability and extent of harm. Over a third of patients experienced an adverse event, and about 32% of adverse events were deemed preventable. Most adverse events occurred in the inpatient setting. Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers and falls. The authors conclude that patient safety remains an important consideration for cancer care that merits further research and improvement efforts.
Lipitz-Snyderman A, Classen D, Pfister D, et al. J Oncol Pract. 2017;13.
Trigger tools are an increasingly important method to detect adverse events. A trigger is a finding identified through structured data that signals a potential adverse event that should be examined by a member of the health care team. In this retrospective cohort study of patients treated for breast, lung, or colorectal cancer, investigators tested a trigger tool with 76 components. After narrowing it to the 49 best-performing triggers, the tool had a positive predictive value of 0.48, meaning that nearly half of the triggers truly represented adverse events. Almost 20% of the triggers represented preventable events. The authors suggest that automation of their trigger tool could lead to real-time identification of adverse events in oncology. A past PSNet interview featured David Classen, one of the pioneers of the trigger tool methodology for detecting adverse events.