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.
Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.
Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.
Ottosen MJ, Sedlock E, Aigbe AO, et al. J Patient Saf. 2021;17:e1145-e1151.
This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46:591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.
This study held focus groups with breast cancer providers to better understand attitudes and experiences regarding communicating with patients about diagnostic errors. Researchers presented three hypothetical vignettes for discussion. Participants identified challenges related specifically to breast cancer as well as challenges stemming from team-based care. To improve communication about these errors, participants recommended educating patients, being honest and empathetic, and focus on the positive and the patient’s future.
Brown SD, Bruno MA, Shyu JY, et al. Radiology. 2019;293:30-35.
This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.
Gallagher TH, Mello MM, Sage WM, et al. Health Aff (Millwood). 2018;37:1845-1852.
Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.
Fisher K, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
White AA, Sage WM, Osinska PH, et al. BMJ Qual Saf. 2019;28:468-475.
High reliability fields like aviation employ policies to require that professionals retire from risky work at a certain age. Researchers interviewed health care system leaders and other stakeholders to devise recommendations for managing physicians as they age. Respondents emphasized patient safety as a guiding principle in addressing aging physicians' performance.
Fisher K, Smith KM, Gallagher TH, et al. J Hosp Med. 2017;12:603-609.
… J Hosp Med … J Hosp Med … Patients can play a crucial role in identifying … Safety Primer and PSNet perspective . … Fisher K, Smith K, Gallagher T, Burns L, Morales C, Mazor K. We Want to Know: … Patients' Perspectives on Breakdowns in Care. J Hosp Med . 2017;12(8):603-609. doi:10.12788/jhm.2783 …
Dellinger P, Pellegrini CA, Gallagher TH. JAMA Surg. 2017;152:967-971.
Physician skills can degrade with age. Other high-risk industries assess older practitioners to confirm cognitive and technical competency, but medicine has been slow to adopt this safety strategy. Exploring how to approach assessments of the aging physician, this review suggests that health care institutions and professional organizations should develop processes and policies that support appropriate skill review within the context of physician well-being and patient safety.