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.
Pavithra A, Mannion R, Sunderland N, et al. J Health Org Manag. 2022;36:245-271.
Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.
Jones A, Blake J, Adams M, et al. Health Policy (New York). 2021;125:375-384.
A key component of patient safety culture is the ability of staff to speak up about patient safety concerns without fear of repercussions. An analysis of 34 studies on speaking-up behavior revealed two narrative themes on why interventions were or were not successful: hierarchical, interdisciplinary, and cultural relationships, and psychological safety. Although interventions varied, there were international similarities in workplace norms and culture. Improving speaking-up behavior in healthcare settings is complex and no intervention is one-size-fits-all.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33:mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Gates PJ, Hardie R-A, Raban MZ, et al. J Am Med Inform Assoc. 2021;28:167-176.
Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.
Bion J, Aldridge CP, Girling AJ, et al. BMJ Qual Saf. 2021;30:536-546.
In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.
Blenkinsopp J, Snowden N, Mannion R, et al. J Health Org Manag. 2019;33:737-756.
Staff willingness to report threats to patient safety is critical to preventing errors and improving safety and is an indicator of an organization’s safety culture. The authors discuss studies exploring what factors influence whistleblowing, organizational responses, and implications for practice or policy. The authors concluded that the existing literature focuses on the decision to speak up. There is limited evidence discussing organizational responses or systems-level changes, yet these actions influence whether the patient safety threats are addressed and if future events will be reported.
Koyama AK, Maddox C-SS, Li L, et al. BMJ Qual Saf. 2020;29:595-603.
Medication administration errors are common and account for a significant fraction of medication errors. This systematic review examined the effect of medication double-checks on medication administration errors. Investigators identified 13 studies (3 were considered high-quality) that demonstrated variable adherence to double-checking protocols. Only one high-quality study showed improvement in medication administration error rates when a double-check took place. No studies demonstrated differences in patient harm with double-checking compared to usual medication administration practice. The authors call for higher-quality studies to determine whether the time-intensive practice of double-checking medication administration confers a meaningful safety benefit. A previous WebM&M commentary discussed an incident involving a nurse who bypassed the double-check policy for verifying the order prior to administration, which led to a medication administration error.
Psychological safety empowers staff to speak up about problems. This commentary highlights how senior managers can help ensure that departmental-level conditions facilitate the reporting of concerns. The authors call for organizations and managers to encourage speaking up and to respond appropriately.
Gates PJ, Baysari M, Mumford V, et al. Drug Saf. 2019;42:931-939.
Consistent measures and terminology of care-related patient harm are still needed in health care. This commentary reviews inconsistencies in the nomenclature used in studies of harm as well as limitations of existing harm classification tools. The authors propose a tool that provides a process for developing a standard classification score to record medication-related patient harm.
Georgiou A, Li J, Thomas J, et al. J Am Med Inform Assoc. 2019;26:678-688.
This review examined whether use of health information technology could improve physician awareness of actionable test results and follow-up of test results. The included studies were of variable quality, and though some did demonstrate improvement in test result management using health information technology, there was no consistent effect. The authors conclude that health information technology alone is not sufficient to close safety gaps in test result management.
Mannion R, Davies H, Powell M, et al. J Health Organ Manag. 2019;33:221-240.
Organizational acceptance of accountability for failures and implementation of solutions are critical to improve safety. This review explores the impact of investigations focused at the individual, practice, and system levels. The authors describe design and operational failings at each level that enable purposeful or accidental patient harm.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Gates PJ, Meyerson SA, Baysari M, et al. Drug Saf. 2019;42:13-25.
This meta-analysis examined the role of computerized provider order entry (CPOE) in preventing pediatric dosing errors. Combining the results of 9 studies, researchers estimate that about 5% of pediatric inpatient medication orders contain a dosing error, but it is unclear whether CPOE reduces pediatric dosing errors. The authors call for further studies with controlled designs to determine the effectiveness of CPOE on improving pediatric medication dosing.
Gates PJ, Meyerson SA, Baysari M, et al. Pediatrics. 2018;142:e20180805.
Pediatric medication errors remain an important focus of safety initiatives. This systematic review examined the extent of preventable patient harm from medication errors for pediatric inpatients. The 22 included studies reported incidence rates ranging from 0 to 74 preventable adverse drug events per 1000 inpatient days. Across all studies, most errors were minor and did not result in patient harm. Use of health information technology was associated with less harm. Emphasizing the challenges of detecting and reporting errors, a related editorial calls for standardizing descriptions of preventable adverse events and harm in pediatrics. A WebM&M commentary addressed the high potential for weight-based medication errors in pediatrics and provided recommendations to help mitigate this risk.
Westbrook JI, Raban MZ, Walter SR, et al. BMJ Qual Saf. 2018;27:655-663.
This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.
Mannion R, Braithwaite J. Int J Health Policy Manag. 2017;6.
Patient safety has been a persistent goal in health care for nearly two decades, but reductions in preventable patient harm remain challenging to sustain. This commentary explores limitations in current system-focused approaches to improvements and advocates for deeper exploration and adoption of strategies that recognize the complexity of the health care environment.