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.
Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.
Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.
Occelli P, Mougeot F, Robelet M, et al. J Patient Saf. 2022;18:415-420.
Understanding patient experience can provide key insights about safety culture. This qualitative study of 80 adult patients concluded that patients’ perspectives of surgical safety are closely tied to the degree of trust they have in their surgeons; this trust is based on the patient’s relationship with their surgeon, communication style, and the patient’s experience during perioperative consultation.
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18:e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17:e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Crit Care Med. 2021;49:e20-e30.
Common nursing procedures, such as bathing patients in their beds, can result in physiologic changes or accidental displacement of medical devices that may be dangerous to the patient. This study of 254 intensive care patients across Western Europe found that serious adverse events occurred in half of patients during bed bathing.
Alsabri M, Boudi Z, Zoubeidi T, et al. J Patient Saf. 2022;18:e124-e135.
In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.
This literature review assesses the current evidence on medical error prevention and management and explores the integration of patient safety into patient care provided by medical humanitarian organizations. The research identified describes patient safety initiatives occurring within three levels: (1) individual staff involved in care provision or management, (2) medical institutions or organizations, and (3) national healthcare systems, laws and regulations and accreditation bodies. Given the absence of overarching authority over healthcare systems and staff turnover within humanitarian organizations, the authors discuss the importance of adapting patient safety models at the organizational level.
Vacher A, El Mhamdi S, dʼHollander A, et al. J Patient Saf. 2021;17:483-489.
Although root cause analysis of adverse events is a foundational patient safety activity, recent studies have demonstrated that it does not always lead to corrective action. Investigators added a standardized tool to identify corrective and preventive actions to their root cause analysis process. They found that the new tool led to identification of more corrective and preventive actions than the preexisting root cause analysis method used in a concurrent control group.
Michel P, Brami J, Chanelière M, et al. PLoS One. 2017;12:e0165455.
This prospective study elicited incident reports from general practitioners for all types of adverse events occurring in primary care. Most events were judged to be preventable, and incidents were frequently due to the organization of care rather than from knowledge gaps on the part of physicians. These results underscore the need to focus on organizational factors in primary care to improve patient safety.
Kristensen S, Hammer A, Bartels P, et al. Int J Qual Health Care. 2015;27:499-506.
In this study, health care organizations that have quality management systems in place had higher safety culture scores than those without such systems. As with prior studies, leaders expressed more positive safety culture than frontline clinicians. This work suggests that ongoing investment in safety culture is needed.
Kringos DS, Suñol R, Wagner C, et al. BMC Health Serv Res. 2015;15:277.
The variable success of patient safety interventions has been attributed to the context in which these strategies have been implemented. In this systematic review, researchers found that contextual aspects that influence success of interventions are not systematically examined or reported, hindering understanding of how context affects implementation of patient safety efforts.
Suñol R, Wagner C, Arah OA, et al. Int J Qual Health Care. 2014;26 Suppl 1:47-55.
Conducted in seven European countries, this observational study reveals that recommended patient safety goals and care quality pathways have not been implemented as planned, and wider variability exists within countries than between countries, consistent with prior studies of safety culture. In a past AHRQ WebM&M interview, Dr. Paul Shekelle discussed this gap between recommended processes and actual clinical practice.
de Rezende BA, Or Z, Com-Ruelle L, et al. BMJ Qual Saf. 2012;21:457-65.
This systematic review identified articles that estimated the cost of adverse events, the cost of patient safety practices, and cost–benefit analyses of error prevention strategies. Of the studies identified, the majority only characterized the cost of adverse events, and few formal cost–benefit analyses were found.
Maurice G de S, Auroy Y, Vincent CA, et al. Qual Saf Health Care. 2010;19:327-31.
This study tracked adoption of a process-oriented safety rule and found that compliance eroded over time, with a major trigger being lack of compliance by a senior staff member. The authors provide caution about the role of policies to promote safety behaviors, particularly if such policies are not prioritized by staff as important.
Michel P, Quenon JL, Djihoud A, et al. Qual Saf Health Care. 2007;16:369-77.
Rather than using traditional retrospective methods, this study employed an observational technique with expert input in estimating that 120,000-190,000 preventable adverse events occur annually in France.
Amalberti R, Auroy Y, Berwick D, et al. Ann Intern Med. 2005;142:756-64.
This commentary builds on the notion that our health care system requires structured efforts to improve safety and reliability. The authors summarize five primary barriers: accepting limitations on maximum performance, abandoning professional autonomy, transitioning from the "mindset of craftsman to that of an equivalent actor," needing system-level arbitration to optimize safety strategies, and simplifying professional rules and regulations. Each of these barriers is discussed with thoughtful perspective on both the associated historical and current contextual factors. In comparing safety strategies with other industries, a specific health care framework is also offered, raising distinctions that pose unique challenges. The article concludes with graphic presentation of a strategic view of safety in health care and the construct for a two-tiered system in which one system achieves "ultrasafe" status while the other does not at a calculated and accepted risk.