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.
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.
Cheraghi-Sohi S, Panagioti M, Daker-White G, et al. Int J Equity Health. 2020;19:26.
To better understand patient safety issues of marginalized groups, this scoping review assessed 67 articles primarily focusing on four patient groups: ethnic minorities, frail elderly, care home residents and those with low socioeconomic status. A variety of patient safety issues were identified, and half of the included studies looked at either medication safety, adverse outcomes, and near misses. This review highlights the need for additional research to understand the intersection between marginalization and the multi-dimensional nature of patient safety issues.
Giles SJ, Parveen S, Hernan AL. BMJ Qual Saf. 2019;28:389-396.
This measure validation study examined the reliability and validity of a patient-reported measure of safety in primary care. The analysis established concurrent validity and reliability, paving the way for measuring patients' perceptions of ambulatory safety.
This study interpreted the results of 48 qualitative studies of patient safety in primary care. The conceptual model that emerged highlights the central role of effective communication between patients and health care staff and the risks electronic systems may introduce by interrupting opportunities for face-to-face communication.
Hernan AL, Giles SJ, O'Hara JK, et al. BMJ Qual Saf. 2016;25:273-80.
Patients may provide valuable insights into potential safety problems. This study describes the development and initial validation of a survey tool for capturing patient feedback about safety in the ambulatory setting. This tool expanded the previously developed patient measure of safety questionnaire to include four primary care–specific domains: continuity of care, external policy context, primary–secondary interface, and referrals. The survey was developed by an expert panel through a modified Delphi process and was well received by patients and staff during face validity testing. This tool aims to provide patient perspectives to primary care organizations to focus improvement efforts in these settings. A prior AHRQ WebM&M interview discussed the emerging field of ambulatory patient safety.
Hernan AL, Giles SJ, Fuller J, et al. BMJ Qual Saf. 2015;24:583-93.
The patient safety field's understanding of safety issues in ambulatory care continues to evolve. Recent studies have helped quantify the incidence of diagnostic errors and medication errors in primary care, indicating that serious safety concerns exist in this arena. This Australian study used qualitative methodology to examine patient and caregiver perceptions of factors affecting safety in ambulatory care. The investigators identified several unique themes related to safety, including difficulties in accessing care, insufficient continuity of care, and poor communication between primary care physicians and specialists. Some of these themes were also found in a prior study of primary care patients in the United Kingdom. The emerging area of ambulatory patient safety was explored in a previous AHRQ WebM&M perspective.
McEachan RRC, Lawton R, O'Hara JK, et al. BMJ Qual Saf. 2014;23:565-73.
Patients can make unique contributions to identifying safety hazards. This study reports on the validation of the Patient Measure of Safety survey tool, designed to elicit patient perceptions of safety in the hospital environment.
Giles SJ, Lawton R, Din I, et al. BMJ Qual Saf. 2013;22:554-62.
Prior studies have shown that patients can detect safety hazards that may not be identified by other techniques, and this study used patient interviews to develop a formal patient questionnaire for measuring patient safety.
Lawton R, McEachan RRC, Giles SJ, et al. BMJ Qual Saf. 2012;21:369-80.
Early efforts to understand and analyze safety incidents in clinical medicine were drawn from a well-known James Reason book and his description of the "Swiss cheese model" for errors. Since that time, many researchers have tried to provide additional frameworks that help define the root causes and key failure modes. This systematic review analyzed nearly 100 articles to establish a contributory factors framework that could be applied to evaluating safety incidents in hospital settings. A set of 20 domains were ultimately outlined with most studies identifying individual factors, communication, and equipment and supplies as most frequently reported. The authors suggest that a consistently adopted framework would substantially improve our ability to not only identify contributing factors but also learn from them.