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.
Usability concerns continue to affect the safe use of electronic health information systems. This commentary describes the role of vendors in improving usability, how regular testing can ensure safety, and the impact of organizational culture on the safe use of information technology over time.
Schwappach DLB, Pfeiffer Y. Patient Saf Surg. 2023;17:15.
Retained surgical items (RSIs) can lead to serious patient harm. Survey findings from 21 clinicians and stakeholders in Switzerland emphasized the importance of addressing production pressures, encouraging a culture of safety and teamwork, and implementation of effective counting procedures to reduce the incidence of retained surgical items.
Pfeiffer Y, Atkinson A, Maag J, et al. J Patient Saf. 2023;19:264-270.
Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.
Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors.
Effective patient safety improvement efforts address safety threats at the individual, interpersonal, and organizational levels. This study characterizes safety measures described in incident reports from German outpatient care settings. Of the 243 preventative measures identified across 160 reports, 83% of preventative measures were classified by the research team as “weak,” meaning that they focus on influencing human behavior rather than on treating underlying problems (e.g., alerts, trainings, double checks).
Historically, there have been many patient safety errors associated with healthcare workers’ failure to speak up and report when they notice a problem. Many studies have identified organizational culture as important in creating a safe environment for workers to report medical errors. This study reports on a multimodal program to educate and train healthcare workers resulting in improvements on speaking up behaviors.
Fridrich A, Imhof A, Staender S, et al. Int J Qual Health Care. 2022;34.
The World Health Organization (WHO) surgical safety checklist (SSC) can improve perioperative outcomes but implementation challenges persist. This study found that peer observation and immediate peer feedback improved SSC compliance and identified primary areas for future efforts to further improve compliance (i.e., reducing interruptions and improving sign outs).
Niederhauser A, Schwappach DLB. Health Sci Rep. 2022;5:e631.
Ensuring that healthcare staff feel comfortable speaking up about safety concerns is an important component of safety culture. This cross-sectional study explored speaking up behaviors and perceptions among healthcare workers in rehabilitation clinics in Switzerland. Barriers to speaking up included expectations of a lack of productive response to the safety concern, presence of patients, and concerns about reactions from involved individuals.
Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11:e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.
Pfeiffer Y, Zimmermann C, Schwappach DLB. J Patient Saf. 2020;Publish Ahead of Print.
This study examined patient safety issues stemming from health information technology (HIT)-related information management hazards. The authors identified eleven thematic groups describing such hazards occurring at a systemic level, such as fragmentation of patient information, “information islands” (e.g., nurses and physicians have separate information sets despite the same HIT system), and inadequate information structures (e.g., no drug interaction warning integrated in the chemotherapy prescribing tool).
Pfeiffer Y, Zimmermann C, Schwappach DLB. BMJ Qual Saf. 2020;29:536-540.
Double checking is one strategy for detecting and preventing medication errors; however, its effectiveness is unclear. This editorial presents a framework intended to further research and clinical practice by defining and classifying checking procedures and differentiating them from other medication-related safety behaviors.
Schwappach DLB, Niederhauser A. Int J Ment Health Nurs. 2019;28:1363-1373.
This study focused on healthcare workers speaking-up behavior in six psychiatric hospitals in Switzerland. The authors found significant differences in speaking-up despite having moderate to high scores on items that were associated with psychological safety. Although nurses reported patient safety concerns more frequently, they also remained silent more often compared with psychologists and physicians, indicating they may feel less psychological safety.
This synthesis of 19 qualitative studies of the second victim phenomenon, or the effects of an adverse outcome or error on clinicians, establishes a framework to characterize second victim experiences. The authors recommend including second victim perspectives into root cause analyses in order to improve safety culture.
Human factors perspectives can inform design and implementation of safety interventions in health care. This commentary summarizes the role of human factors engineering and checklists as safety improvement strategies in plastic surgery. The authors highlight nontechnical skill development, checklist customization, raising of concerns, and safety assessment as key areas of focus for the specialty.
Schwappach DLB, Gehring K. PLoS One. 2014;9:e104720.
This survey study presented physicians and nurses with four scenarios involving error and rule violations and found wide variation in their reported likelihood of voicing safety concerns. This emphasizes the need to bolster safety culture such that health care workers feel empowered to speak up to identify and mitigate errors.
Schwappach DLB, Gehring K. BMC Health Serv Res. 2014;14:303.
Although doctors and nurses in an oncology unit all agreed on the importance of speaking up in unsafe situations, they described various barriers to actually doing so, including the potential to damage relationships and concern about the accuracy of their own assessment of the situation.
Gehring K, Schwappach DLB, Battaglia M, et al. Int J Qual Health Care. 2013;25:394-402.
Health care workers' perception of safety culture in the hospital has been widely studied, but there is comparatively less evidence regarding safety culture in primary care. This survey of physicians and nurses at 472 primary care practices in Switzerland revealed findings similar to those in the inpatient setting. For example, nurses generally had a lower perception of safety climate than physicians. Staff at multi-specialty or hospital-affiliated clinics generally perceived stronger safety climate than staff at single physician practices, as did practices that regularly held team meetings or participated in quality improvement activities. The study used a modified version of the Safety Attitudes Questionnaire.
Borchard A, Schwappach DLB, Barbir A, et al. Ann Surg. 2012;256:925-33.
Checklists have garnered wide publicity due to their use in seminal studies demonstrating their effectiveness at preventing central line infections and surgical complications. This systematic review evaluated the effectiveness and critical factors for successful implementation of surgical checklists. The authors found strong evidence that using checklists improves perioperative clinical outcomes. However, checklist usage varied widely across studies, indicating that careful attention must be paid to how checklists are implemented in clinical settings.