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.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
This article describes an innovative expert consensus process to generate a contemporary list of chart-review based triggers and adverse event measures for assessing the incidence of inpatient and outpatient adverse events. A panel of 71 experts from nine institutions identified 218 triggers and measures with high or very high clinical importance deemed suitable for chart review and 198 were found suitable for electronic surveillance; 192 items were suitable for both.
Singh H, Sittig DF, Gandhi TK. BMJ Qual Saf. 2021;30:141-145.
… safety , and (3) removing barriers to using health IT (e.g., EHRs, telemedicine) to improve safety and how to create … methods to prevent harm. … Singh H, Sittig DF, Gandhi TK. BMJ Qual Saf. 2021;30(2):141-145. …
The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.
Franklin BJ, Gandhi TK, Bates DW, et al. BMJ Qual Saf. 2020;29:844–853.
Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.
Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.
… the definition of harm to include non-physical harms (e.g., psychological harms), harms to caregivers and the … , and (4) patient engagement and codesign of healthcare. … Gandhi TK, Feeley D, Schummers D. Zero harm in health care …
… results to patients in a timely and consistent fashion. … EricPoon, MD, MPH … Chief Health Information Officer Duke … Research and Quality; January 2018. [Available at] 13. Roy CL, Rothschild JM, Dighe AS, et al. An initiative to … 2015;42:1213-1217. [go to PubMed] 16. Singh H, Wilson L, Reis B, Sawhney MK, Espadas D, Sittig DF. Ten strategies …
Dalal A, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
McGaffigan PA, Ullem BD, Gandhi TK. Jt Comm J Qual Patient Saf. 2017;43:267-274.
Board and leadership engagement is considered critical for advancing patient safety. In this survey study, safety and quality leaders rated board and executive leaders as less engaged in patient safety and quality compared to executive and board member self-perceptions. These findings suggest room for enhanced executive engagement.
Tsou AY, Lehmann CU, Michel J, et al. Appl Clin Inform. 2017;8:12-34.
The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.
System failures can remain undetected over time in large organizations. This perspective describes elements of a health care research environment that enabled lapses in safety, such as financial pressures and shifting priorities. The author calls for industry-wide learning from this example to ensure that patient safety remains a priority and that organizations invest and commit to an infrastructure that encourages safety.
Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.
Gandhi TK, Berwick DM, Shojania KG. JAMA. 2016;315:1829-30.
This commentary discusses findings from the National Patient Safety Foundation report investigating the state of patient safety in the 15 years after To Err Is Human. Focusing on the recommendation that leadership establish and sustain a culture of safety, the authors describe how leaders can engage board members and organizational leadership in this work and highlight the need to provide leaders with education and practical tools.
This study examined whether locating inpatient medical teams on specific units, known as regionalization, would result in improved communication. Investigators found that the rate of adverse events and the extent of physician–nurse agreement about the care plan did not significantly change after this regionalization occurred. More robust interprofessional interventions are needed to enhance patient safety.
Lacson R, O'Connor SD, Sahni A, et al. BMJ Qual Saf. 2016;25:518-524.
Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.