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.
Wilson C, Janes G, Lawton R, et al. BMJ Qual Saf. 2023;32:573-588.
Feedback interventions (e.g., debriefing, peer-to-peer, audit, and feedback) can encourage learning from safety events and improve quality of care. This systematic review of 48 studies found that providing feedback to emergency medical services (EMS) personnel can improve documentation and adherence to protocols, with some studies also documenting improvements in clinical decision-making and cardiac arrest performance.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.
Wilson C, Howell A-M, Janes G, et al. BMC Health Serv Res. 2022;22:296.
Feedback is an essential component of performance improvement and patient safety. Researchers conducted semi-structured interviews with emergency medical services (EMS) professionals in the United Kingdom about their perspectives on how feedback impacts patient care and safety. Findings highlight strong desire for feedback and concerns that inadequate feedback could inhibit learning from mistakes, limit professional development, and negatively impact patient safety.
Chaudhry NT, Franklin BD, Mohammed S, et al. Pharmacy (Basel). 2021;9:198.
Data that is collected for clinical care and then reused to improve quality of patient care is referred to as secondary use of data (SUD). This review identified enablers and barriers to successful use of SUD to improve medication safety. The authors developed an integrated framework to describe the processes, mechanisms, and barriers for SUD.
Reynolds M, Jheeta S, Benn J, et al. BMJ Qual Saf. 2017;26:240-247.
Prescribing errors are a common source of harm for hospitalized patients. This study describes a multifaceted intervention to improve feedback and prevent resident physician prescribing errors. Despite improvements in numerous process measures, rates of errors did not significantly change.
Benn J, Burnett S, Parand A, et al. BMJ Qual Saf. 2012;21:559-68.
The United Kingdom's Safer Patients Initiative resulted in modest improvement in safety culture at participating hospitals. This article also discusses the program implementation factors that appeared to be associated with improved safety culture.
Parand A, Burnett S, Benn J, et al. J Eval Clin Pract. 2011;17:1184-90.
Focused on achieving improvements in patient safety and quality, the United Kingdom’s Safer Patients Initiative (SPI) is a large-scale effort targeting 24 care organizations. The initiative emphasizes changes at the organizational level, improvements in reliability of frontline care processes, and careful attention to communication, leadership, and safety culture. This study evaluated perceptions among managers and frontline staff participating in the SPI and found a number of differing opinions on the same elements of the program. For instance, managers were likely to report a more positive outcome and larger improvements on staff morale and job satisfaction, whereas staff perceived greater improvements in the timeliness of care delivered. The authors suggest that their findings carry important implications as the differing perceptions identified may provide key strategies for understanding and monitoring success of such initiatives moving forward.
Parand A, Burnett S, Benn J, et al. Qual Saf Health Care. 2010;19:e44.
Despite the success of large-scale patient safety initiatives such as the Keystone ICU project, many institutions still struggle with engaging staff in new safety programs. This qualitative study of institutions enrolled in the United Kingdom’s Safer Patients Initiative (SPI) identified several factors affecting institutions’ ability to launch safety initiatives, including the organizational context and history, the design of specific initiatives, and the role of local and external expertise in guiding new initiatives. These factors are also important drivers of local safety culture. A prior report based on the SPI discusses the local impact of the program and factors that predicted success at the institutional level.
Burnett S, Benn J, Pinto A, et al. Qual Saf Health Care. 2010;19:313-7.
Implementation of large-scale safety improvement programs requires learning organizations—organizations with the capacity for change. The Safer Patients Initiative was implemented at four United Kingdom sites in 2004 in collaboration with the Institute for Healthcare Improvement with the goal of reducing preventable harm. This qualitative study evaluated the readiness of each organization to undertake this initiative, and found that a positive safety culture, a history of organizational leadership and involvement in safety initiatives, and availability of information technology for quality measurement were important predictors of successful implementation. The importance of strong organizational leadership in improving safety was recognized by The Joint Commission in a Sentinel Event Alert.
Benn J, Burnett S, Parand A, et al. J Eval Clin Pract. 2009;15:524-40.
The United Kingdom Safer Patients Initiative is a large-scale effort to reduce preventable harm in hospitals, including medication errors, health care–associated infections, and cardiopulmonary arrests. Implementation of this program is being conducted according to the principles of continuous quality improvement in collaboration with the Institute for Healthcare Improvement. This mixed methods study evaluates the first phase of the project by soliciting the perceptions of project leaders at four hospitals with the goal of analyzing the local impact of the initiative. Respondents discussed the role of safety culture in facilitating success of the project and identified other local factors that enabled safety improvements.