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.
Kasda EM, Robson C, Saunders J, et al. J Patient Saf Risk Manag. 2020;25:156-158.
This article describes one academic medical center’s use of the Donabedian framework to rapidly identify and mitigate COVID-19 related safety concerns. This data-driven approach to systems learning is generalizable beyond the current pandemic and can be applied to other organizational changes.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.
In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.
Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2017;92:608-613.
Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.
Arbaje AI, Werner NE, Kasda EM, et al. J Patient Saf. 2020;16:52-57.
Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.
Sutcliffe K, Paine LA, Pronovost P. BMJ Qual Saf. 2017;26:248-251.
… Saf … Health care has recently adopted high reliability as a goal, but progress to reaching that standard has been … achieving high reliability must establish and sustain a culture of safety throughout the health care system. …
Dang D, Nyberg D, Walrath JM, et al. Am J Med Qual. 2014;30:470-476.
… Am J Med Qual … Health care has a history of tolerating intimidating and disruptive behavior … high reliability in measuring disruptive behavior. A past AHRQ WebM&M perspective discusses how to identify and manage …
Walrath JM, Dang D, Nyberg D. J Nurs Care Qual. 2012;28.
… Nursing Care Quality … J Nurs Care Qual … Health care has a history of tolerating intimidating and disruptive behavior … engage in demeaning or threatening behaviors. Conducted at a large academic medical center, this study used a newly developed survey to determine the incidence of …