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.
Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;182:720-728.
Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.
Sheetz KH, Dimick JB, Englesbe MJ, et al. Health Aff (Millwood). 2019;38:1858-1865.
Since 2013, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) has reduced payments to hospitals with elevated rates of specific outcomes deemed to be preventable sources of harm. To better understand the impact of the HACRP in Michigan, this study used a surgical registry to compare trends in rates of outcomes targeted by the program to concurrent trends for other hospital-acquired conditions, such as postoperative cardiac arrest and postoperative pneumonia. The authors saw an overall decrease in all hospital-acquired conditions over the eight-year study period but did not identify a statistically significant change in the rate of HACRP-targeted versus non-targeted conditions. The authors acknowledge that these findings may not be generalizable nationally because of robust quality improvement efforts already in place in Michigan, such as existence of other quality improvement efforts, such as the AHRQ-recognized Michigan Surgical Quality Collaborative and the Hospital Engagement Network
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.
Sankaran R, Sukul D, Nuliyalu U, et al. BMJ. 2019;366:l4109.
The Centers for Medicare and Medicaid Services impose financial penalties on hospitals whose Medicare patients experience higher rates of hospital-acquired conditions (HACs) like urinary tract infections and pneumonia. Hospitals caring for more patients with low socioeconomic status receive more penalties under this program than hospitals caring for wealthier populations. Investigators attempted to assess whether hospitals penalized under the program reduced HAC rates. They found that penalized hospitals did not have lower HAC rates or improve other measures of clinical quality. This finding raises questions about whether financial penalties effectively enhance patient safety. By contrast, quality improvement collaboratives like Partnership for Patients have markedly reduced HACs. A PSNet interview with former AHRQ director Andrew Bindman explored strategies for reducing health care–acquired harm in the hospital and ambulatory settings.
The FDA recently raised awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. This commentary spotlights how payers, hospitals, and clinicians can prevent harm related to robotic surgical device use. Strategies to improve safety include enhanced credentialing, device-specific training, and informed consent. A WebM&M commentary discussed an incident of harm associated with robotic-assisted surgery.
This secondary analysis of data from a repository of surgical outcome data compared hospitals that participate in a benchmarking program, hospitals that participate in benchmarking and collaborative quality improvement, and hospitals that do not participate in either program. After adjusting for patient factors and ongoing improvement over time, investigators found that hospitals participating in benchmarking and collaborative improvement had the lowest in-hospital mortality. The authors conclude that quality improvement collaboratives can enhance patient safety.
Jaffe TA, Hasday SJ, Knol M, et al. J Surg Res. 2017;218:361-366.
This survey of academic surgeons found that the majority believe that credentialing and privileging requirements for new procedures are not rigorous enough to ensure patient safety. They also felt that requirements should be tailored to individual surgical experience rather than standardized by procedure type. These results suggest that practicing surgeons would welcome examination of current credentialing and privileging to ensure patient safety.
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266:582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Dossett LA, Kauffmann RM, Lee JS, et al. Ann Surg. 2018;267:1077-1083.
Prior studies demonstrate that disclosure of medical errors to patients is central to maintaining a therapeutic provider–patient relationship. However, little is known about physicians' beliefs regarding the disclosure of other clinicians' errors. Investigators interviewed 30 oncologists to understand their attitudes toward disclosure of medical errors occurring prior to the referral of a patient. Most believed that error disclosure did not benefit patients and disclosure practices varied significantly.
This commentary explores the responsibility of organizations, device manufacturers, and clinicians for ensuring surgeon technical expertise in the use of robotic surgical equipment. The authors describe how hospitals and individual practitioners can enhance their capabilities with new technology to ensure safe patient care.
Scally CP, Ryan AM, Thumma JR, et al. Surgery. 2015;158:1453-61.
Duty hour reform was enacted to improve patient safety, but its effect remains unclear. This study found no difference in surgical complication rates before and after implementation of 2011 duty hour reforms, using nonteaching hospitals as a reference population. These results add to the literature suggesting that duty hours had no substantial impact on patient outcomes.
Learning curves with new devices can hinder patient safety. This commentary explores legal and accountability issues associated with the use of the da Vinci surgical system, particularly whether the hospital or physician is responsible for training, credentialing, and privileging to utilize the device. The authors suggest that the hospital be responsible for providing opportunities to develop skills and confirm that physicians are prepared to safely use new technologies.
Osborne NH, Nicholas LH, Ryan AM, et al. JAMA. 2015;313:496-504.
This large study used 9 years of national fee-for-service Medicare data to examine differences in surgical outcomes between hospitals participating in the National Surgical Quality Improvement Program (NSQIP) and nonparticipating hospitals. There was no statistically significant difference in the rate of improvement for any of the measured outcomes—risk-adjusted 30-day mortality, serious complications, reoperation, or 30-day readmissions—at 1, 2, or 3 years after enrollment in NSQIP versus well-matched controls. Notably, over 6 years there has been a trend toward reductions in mortality, serious complications, and readmissions across hospitals, regardless of NSQIP participation. The results of this study strengthen those of the study by Etzioni and colleagues in the same issue of the Journal of the American Medical Association. In an accompanying editorial, Dr. Donald Berwick states, "it is implausible to conclude that knowing results is not useful—perhaps essential—for systematic improvement of outcomes," but that hospitals must realize measurement alone is insufficient.
Initial enthusiasm for the role of checklists in reducing perioperative complications has been tempered by subsequent studies that did not replicate the safety improvements. This study evaluated the effect of the Keystone Surgery program, which combined an evidence-based checklist and the comprehensive unit-based safety program to enhance safety culture. Comparison of Keystone Surgery hospitals to those that did not implement the intervention found no differences in outcomes (including surgical site infections and 30-day mortality) between groups. The investigators acknowledge that many participating sites lacked the infrastructure to collect and regularly feed back performance data to frontline providers, which may have limited the effectiveness of the intervention. The study adds to a growing body of literature that emphasizes the role of effective implementation and monitoring in ensuring the success of checklist-based interventions. A PSNet interview and perspective explore the development and use of checklists to augment safety in health care.
Reames BN, Scally CP, Thumma JR, et al. Med Care. 2015;53:87-94.
The introduction of surgical safety checklists is often seen as a milestone accomplishment for the patient safety field, based on impressive reductions in mortality and complications shown in early international studies. More recently, a large trial in Ontario failed to show significant improvements following mandatory checklist adoption. However some concerns were raised related to methodological limitations, such as a lack of a comprehensive program for implementation. This study examined the effects of the Keystone Surgery program, a statewide effort in Michigan hospitals to introduce a surgical safety checklist along with a comprehensive unit-based safety program. Using Medicare claims data, no differences were found in adjusted 30-day mortality, complication rates, reoperations, or readmissions for hospitals participating in Keystone Surgery. Unlike the prior Ontario study, this study assessed outcomes up to 3 years following implementation and included a standardized and comprehensive implementation strategy. These results cast further doubt on the power of surgical safety checklists to improve outcomes when implemented in non-research settings.
This study used clinical registry data from the Michigan Bariatric Surgery Collaborative to develop a composite outcome score. This measure was more closely associated with future performance than other surgical quality measures.
Nicholas LH, Osborne NH, Birkmeyer JD, et al. Arch Surg. 2010;145:999-1004.
Hospitals are now required to report adherence to measures intended to prevent post-surgical complications, including surgical site infections. These measures are being publicly reported by groups including the Centers for Medicare and Medicaid Services. However, this analysis found that high levels of adherence to these accountability measures were not correlated with postoperative mortality, surgical site infection rate, or other complications, calling into question the value of public reporting of such measures.