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.
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
The COVID-19 pandemic increased symptoms of physician burnout, including emotional exhaustion, which can increase patient safety risks. This cross-sectional study examined emotional exhaustion among healthcare workers at two large health care systems in the United States before and during the COVID-19 pandemic. Respondents reported increases in emotional exhaustion in themselves and perceived exhaustion experienced by their colleagues. The researchers found that emotional exhaustion was often clustered in work settings, highlighting the importance of organizational climate and safety culture in mitigating the effects of COVID-19 on healthcare worker well-being.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
Psychological safety (PS) is integral to ensuring healthcare workers feel comfortable asking questions and raising patient safety concerns. A novel PS assessment was administered to over 10,000 healthcare workers and support staff in one academic health system. The scale showed a significant correlation with safety culture, especially among those exposed to institutional PS programs (i.e., Safety WalkRounds and Positive Leadership WalkRounds).
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Patient Saf. 2021;47:403-411.
Health system leadership practices can influence patient safety. Using a cross-sectional survey of clinical and non-clinical healthcare workers, this study found that Positive Leadership WalkRounds – where leadership conduct rounds and ask staff about what is going well and what can be improved – was associated with improved safety culture and healthcare worker well-being. Healthcare workers exposed to Postive Leadership WalkRounds were more likely to report readiness to engage in quality improvement activities, positive perceptions of teamwork and work-life balance norms and were less likely to report emotional exhaustion in themselves and their colleagues.
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Saf. 2021;47:306-312.
Healthcare workers may experience distress following adverse events. This survey of healthcare workers found that one-third had at least one colleague who experienced trauma after an adverse event. The authors also found that perceived institutional support was associated with a better safety culture and lower emotional exhaustion, highlighting the importance of support programs.
Rehder KJ, Adair KC, Hadley A, et al. Jt Comm J Qual Saf. 2020;46:18-26.
This study used a brief survey to evaluate disruptive behaviors in one large health system, and its relationship to safety culture. Disruptive behaviors (most commonly bullying and inappropriate discontinuation of communication, such as hanging up the phone) were noted by more than half of individuals surveyed and occurred in nearly all work settings. Greater exposure to disruptive behaviors was associated with poorer teamwork climate, safety climate, and job satisfaction
Holmgren J, Co Z, Newmark L, et al. BMJ Qual Saf. 2020;29:52-59.
A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.
… the name of patient safety. … The Commentary … by Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD … Saf. 2018;27:261-270. [go to PubMed] 2. Adair KC, Quow K, Frankel A, et al. The Improvement Readiness scale of the … Teamwork and Cooperative Working. Chichester, UK: John Wiley & Sons Ltd; 2003:255-275. ISBN: 9780471485391. …
Classen D, Li M, Miller S, et al. Health Aff (Millwood). 2018;37:1805-1812.
Most health care organizations primarily rely on retrospective techniques such as incident reporting systems to detect and respond to patient harm. Retrospective techniques do not capture a substantial proportion of patient safety events and are not effective for real-time feedback or safety incident prevention. By contrast, electronic health record–based trigger tools detect safety incidents in real time. Investigators developed and piloted the patient safety active management (PSAM) at two large community hospitals. The PSAM employed machine learning and expert clinician review of years of adverse event data to refine the Institute for Healthcare Improvement Global Trigger Tool and distilled this into a real-time risk score for patient safety incidents. The PSAM identified 10 times more safety incidents than were detected through retrospective techniques. It reliably predicted both serious adverse events and mortality. A prior PSNet perspective explored how to leverage electronic health records to enhance safety.
The Moore Foundation provides free access to this article.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Stockwell DC, Landrigan CP, Schuster MA, et al. Pediatr Qual Saf. 2018;3:e081.
The Centers for Medicare and Medicaid Services (CMS) has successfully reduced preventable harm from hospital-acquired conditions (HACs) through financial penalties to hospitals. Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list, raising concern about whether institutions may be neglecting other types of preventable harm. Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list. Only 58 of 240 harms were considered HACs. Some common harms identified outside the scope of HACs were intravenous catheter infiltration, surgical complications, and pain. Prior WebM&M commentaries have discussed harms from hospital-acquired infections as well as the unintended consequences of public hospital quality reporting.
This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.
Sammer C, Hauck L, Jones C, et al. J Patient Saf. 2020;16.
Trigger tools harness electronic health record data to detect and ameliorate safety hazards. Triggers can identify errors in a specific area or more globally measure an organization's safety. Researchers at a large community hospital developed a robust trigger tool to measure all-cause patient harm and assessed what predicted lower all-cause harm at the unit level. Units with increased employee engagement, stronger safety culture, and better patient experience were all correlated with lower rates of all-cause harm. The authors suggest that their tool could serve as a composite measure of patient safety, replacing the hundreds of safety metrics institutions are required to report. A PSNet perspective reinforced the value of a strong safety culture and discussed techniques for bringing about culture change.
Sexton B, Adair KC, Leonard MW, et al. BMJ Qual Saf. 2018;27:261-270.
Achieving an optimal culture of safety is a central component of patient safety. Prior research supports that higher levels of employee engagement are correlated with improved perceptions of safety culture and that higher rates of burnout are associated with more negative perceptions of safety culture. Leadership WalkRounds has been touted as an intervention to improve safety culture, although the evidence for its efficacy has been mixed. In a more recent study, clinical units that received feedback from walkrounds had lower rates of burnout and more positive perceptions of safety culture. In this cross-sectional survey study, researchers analyzed the relationship between receiving feedback on the actions resulting from walkrounds and health care employees' perceptions of safety culture, engagement, burnout, and work–life balance across 829 settings. Work environments in which walkrounds were conducted with feedback had higher safety culture and employee engagement scores. A past PSNet interview and Annual Perspective discussed the relationship between burnout and patient safety.
Lipitz-Snyderman A, Pfister D, Classen D, et al. Cancer. 2017;123:4728-4736.
Cancer care has been the setting for seminal, practice-changing errors. This retrospective study aimed to identify adverse events in cancer care through medical record review, using a random sample of breast, colorectal, and lung cancer cases from 2012. As with prior studies, physician investigators determined preventability and extent of harm. Over a third of patients experienced an adverse event, and about 32% of adverse events were deemed preventable. Most adverse events occurred in the inpatient setting. Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers and falls. The authors conclude that patient safety remains an important consideration for cancer care that merits further research and improvement efforts.
Schiff G, Nieva HR, Griswold P, et al. Med Care. 2017;55:797-805.
A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.