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.
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
Sherwood R, Bismark M. BMJ Qual Saf. 2020;29:113-121.
Confidential skill assessments have been recommended as a strategy to ensure competence among aging surgeons. In this qualitative study, the authors describe opinions from 52 experts on how to manage potential concerns associated with aging surgeons.
Moore JS, Mello MM, Bismark M. Bioethics. 2019;33:948-957.
Patient engagement is now acknowledged as a cornerstone of patient safety, but the perspectives of patients who have experienced adverse events remain understudied. This interview study of 92 patients who had experienced iatrogenic injury identified several insights about the aftermath of adverse events. As with prior studies, researchers found that patients expressed a desire to be heard. Participants had positive perceptions of patient safety research and expressed a desire that others learn from the adverse event they experienced. The authors suggest that institutional review boards permit investigators to approach patients who have experienced adverse events to participate in studies, rather than prohibit such studies due to fear of causing further psychological harm. They also recommend that researchers discuss these adverse events with patients through a reciprocal lens, expressing support and sympathy rather than maintaining an emotionally distant stance. A previous PSNet interview with the lead author discussed disclosure and apology in health care.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Kachalia A, Sands K, Van Niel M, et al. Health Aff (Millwood). 2018;37:1836-1844.
Health care systems have implemented communication-and-resolution programs (CRPs) to respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error disclosure, investigation into the cause, an apology, and early compensation. Some systems have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that CRPs will increase malpractice costs has limited widespread implementation. Investigators analyzed malpractice costs at four hospitals that implemented CRPs compared with matched control hospitals. Communication-and-resolution programs had either a positive or neutral effect on all metrics including new claims rate, paid claims rate, and total liability costs. This analysis is the most robust to date supporting CRP programs as previous studies have lacked a control group. A previous PSNet interview with Michelle Mello discussed other intersections between patient safety and the law.
Gallagher TH, Mello MM, Sage WM, et al. Health Aff (Millwood). 2018;37:1845-1852.
Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.
Haffajee RL, Mello MM, Zhang F, et al. Health Aff (Millwood). 2018;37:964-974.
The opioid epidemic is a well-recognized national patient safety issue. High-risk opioid prescribing can contribute to misuse. Provider prescribing has come under increased scrutiny and several states have implemented prescription drug monitoring programs (PDMPs). Prior research suggests that such programs have the potential to reduce opioid-related harm. This study used commercial claims data to assess the impact of PDMPs implemented in four states in 2012–2013 on opioid prescribing. By the end of 2014, all four states with PDMPs demonstrated a greater reduction in the average amount of morphine-equivalents prescribed per person per quarter compared with states without these programs. One state demonstrated a decrease in the percentage of people who filled an opioid prescription. The authors conclude that PDMPs have the potential to reduce opioid use and improve prescribing practices. An Annual Perspective highlighted safety issues associated with opioid medications.
Moore J, Bismark M, Mello MM. JAMA Intern Med. 2017;177:1595-1603.
Communication-and-resolution programs have demonstrated declines in malpractice claims in early studies, but implementing these programs effectively has been a challenge. This study is the first to examine patient perspectives on communication-and-resolution programs. Investigators interviewed 30 patients, most of whom experienced harm. Respondents expressed a desire for providers to listen to their perspectives without interruptions, consistent with prior studies. Although patients wished for information regarding what hospitals planned to do to prevent similar events in the future, most reported that they did not receive such follow-up. The authors state that their findings represent opportunities to improve communication-and-resolution programs. A past PSNet interview discussed an organization's pioneering efforts to implement a communication-and-response system.
Mello MM, Kachalia A, Roche S, et al. Health Aff (Millwood). 2017;36:1795-1803.
Communication-and-resolution programs, in which health systems and liability insurers disclose errors, apologize, and offer compensation to patients and families, led to declines in malpractice costs in prior studies. However, some have raised concerns that actual implementation of these programs may not have the same benefits. This prospective observational study reports results following implementation of a communication-and resolution-program at four hospitals in Massachusetts. Investigators report that the program was largely implemented as intended. Less than 10% of events met criteria for compensation, and the median payment was $75,000, allaying concerns about high costs of these programs. Lawsuits occurred in 5% of cases. The authors conclude that these results support further implementation and evaluation of communication-and-resolution programs. A recent PSNet interview with Michelle Mello, the lead author of this study, discussed legal issues in patient safety.
Exploring patient-centered alternatives to traditional malpractice litigation is an ongoing patient safety consideration. Investigators conducted interviews with patients, health care administrators, and malpractice lawyers in New Zealand, where a no-fault scheme has superseded malpractice litigation. Several themes about postincident reconciliation emerged. Patients noted the importance of feeling listened to and the need for prompt apology from providers involved in the adverse event. All stakeholders supported the practice of direct engagement between the treating provider and patient or family as a critical step for reconciliation. Patients and lawyers reported benefits to early involvement from lawyers to support reconciliation. The authors conclude that reconciliation following adverse events requires approaches tailored to individual patient and family needs. An accompanying editorial discusses the importance of transparency for reconciliation and trust.
Scheduling overlapping procedures is perceived as risky, despite lack of robust evidence regarding its impact on patient safety. This commentary explains that the practice is primarily detrimental to the physician–patient relationship and that building trust is a key strategy to manage this concern. The authors suggest transparency with patients about scheduling practices and hospital oversight to ensure accountability would assist in establishing the trust in overlapping surgeries.
… when necessary, to shepherd them away from patient care. … DavidStuddert, LLB, ScD, MPH … Professor of Medicine and Law … [Available at] 9. Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. Identification of doctors at risk of …
This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.
Schaffer A, Jena AB, Seabury SA, et al. JAMA Intern Med. 2017;177:710-718.
This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.
Mello MM, Greenberg Y, Senecal SK, et al. Health Serv Res. 2016;51 Suppl 3:2583-2599.
Communication-and-resolution programs underscore the importance of early disclosure of medical error to patients and families. Prior research highlights implementation challenges associated with these efforts. Investigators analyzed 125 adverse event cases from 5 New York City hospitals over a 22-month period following the implementation of communication-and-resolution programs. The majority of cases did not involve substandard care, and disclosure occurred in more than 90% of cases.