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.
Incident reporting systems and root cause analyses are the primary mechanisms by which adverse events are identified and reviewed. This analysis of incident reports occurring at one hospital in Sweden found that the handling, causes, and actions taken to prevent recurrence of injuries were similar across three severity levels (injuries leading to deaths, permanent harm, or temporary harm). However, the feedback generated based on these reports was primarily used at the department level and did not lead to organizational learning.
Ericsson C, Skagerström J, Schildmeijer K, et al. BMJ Qual Saf. 2019;28:657-666.
Patient engagement in safety is considered a best practice and a National Patient Safety Goal, but less is known about patients' perceptions regarding this topic. In this survey study involving 1445 patients in Sweden, researchers found that more than 80% of respondents felt comfortable directing questions to doctors and nurses. Patients who had filed a formal complaint reporting a safety concern were found to believe with greater certainty that the patient perspective can improve the safety of care.
Skagerström J, Ericsson C, Nilsen P, et al. Nurs Open. 2017;4:230-239.
This qualitative study examines nurses' perspectives regarding patient engagement. Nurses reported that they believe health care workers and patients share responsibility for patient participation in care. Participants identified barriers to patient engagement, including time limitations, insufficient continuity with other providers, and lack of trust.
Öhrn A, Ericsson C, Andersson C, et al. J Patient Saf. 2018;14:17-20.
Failure mode effect analysis is a widely used method of prospectively detecting safety hazards, but evidence of its effectiveness is lacking. This study of 117 FMEAs from 3 hospitals in Sweden found that the recommended safety interventions were implemented in more than three-quarters of cases within a few years.