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.
Goldman J, Rotteau L, Flintoft V, et al. BMJ Qual Saf. 2023;32:470-478.
Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.
Jeffs L, Bruno F, Zeng RL, et al. Jt Comm J Qual Patient Saf. 2023;49:255-264.
Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;31:867-877.
Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13:98.
Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
Sears NA, Blais R, Spinks M, et al. BMC Health Serv Res. 2017;17:400.
Adverse events occur frequently in the home care setting. A previous study estimated that about 10% of patients receiving home care experienced an adverse event, and research suggests that a significant proportion of these may be preventable. Early identification of patients at increased risk for harm in the home care setting may help inform hospital discharge planning and improve patient safety. Analyzing data from two prior Canadian home care patient safety studies, researchers found that both increased dependency for instrumental activities of daily living and a higher number of comorbid medical conditions placed patients at greater risk for adverse events. A past PSNet perspective discussed safety issues associated with care transitions after hospital discharge.
Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf. 2016;25:e7.
The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.
Wong BM, Dyal S, Etchells E, et al. BMJ Qual Saf. 2015;24:272-81.
This prospective error investigation study combined a trigger approach to identify possible adverse events with medical record review and structured interviews to determine underlying causes for adverse events. Investigators found that a myriad of factors contribute to adverse events, and multiple distinct interventions would be needed to prevent the detected events. The authors advocate for a framework to classify underlying causes together when they can be addressed by the same intervention.
Parshuram CS, Amaral ACKB, Ferguson ND, et al. CMAJ. 2015;187:321-9.
This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.
Srigley JA, Furness CD, Baker R, et al. BMJ Qual Saf. 2014;23:974-980.
Hand hygiene is a core practice for decreasing health care–associated infections, but achieving compliance has proven difficult. In this study, hand hygiene rates were about threefold higher when an auditor was present compared with hallway dispensers that were not visible by a direct observer. Since many publicly reported hand hygiene rates are based on direct auditor observations, this study suggests these metrics may be greatly inflated and unreliable. A prior WebM&M perspective reviewed recent strategies for promoting and monitoring hand hygiene.
Doran DM, Baker R, Szabo C, et al. Int J Health Care Qual. 2014;26:136-143.
Home care is one of the fastest growing sectors of the health care field, but recent research has raised safety concerns among patients receiving home services. A prospective cohort study revealed that 10% of home care patients experienced an adverse event, an incidence comparable to that found in hospitalized patients. This study used a Delphi approach to determine the types of adverse events in home care that should be considered serious (in terms of the level of patient harm) and preventable. Four types of serious preventable events were identified: inappropriate client service plans, medication errors requiring emergency treatment, catheter-associated infections, and incidents related to care that did not fall within practice standards. The authors advocate for using this classification scheme as the basis for a home care adverse event reporting system, analogous to state reporting systems for serious errors occurring in hospitalized patients.
O'Beirne M, Reid R, Zwicker K, et al. J Patient Saf. 2013;9:211-8.
This study estimated a cost of approximately CAD $260,000 over 4 years to develop and run a safety learning system for family physician clinics in Calgary, Alberta. Policy makers and payers may need to determine whether there is an adequate return on investment for the sustainability of these types of programs.
Blais R, Sears NA, Doran D, et al. BMJ Qual Saf. 2013;22:989-997.
Adverse events are thought to be common in patients receiving home health care, but few high-quality studies address this issue. This prospective cohort study found that 1 in 10 home care patients experienced an adverse event each year, and more than half of these events were considered preventable.
Soong C, Daub S, Lee J, et al. J Hosp Med. 2013;8:444-9.
The hospital discharge process is often disorganized and lacks standardization. As a result, adverse events after hospital discharge are disturbingly common. This study reports on a multidisciplinary, collaborative effort—involving hospitalists, primary care physicians, home care and bedside nurses, and pharmacists—to develop a standardized hospital discharge checklist. The resulting tool is designed to be used daily during hospitalization as part of interprofessional discharge planning rounds and consists of seven domains that address key aspects of the hospital-to-home transition, including medication reconciliation and communication between physicians. Further validation will be required to demonstrate that this checklist can prevent adverse events in broad hospitalized patient populations.
Matlow A, Baker R, Flintoft V, et al. CMAJ. 2012;184:E709-718.
Hospitalized children are particularly vulnerable to specific types of errors, such as medication errors. This Canadian study used a trigger tool approach to estimate the frequency of all types of adverse events in hospitalized children, and found that nearly 1 in 10 pediatric patients suffers an adverse event while hospitalized. This prevalence is similar to classic studies performed in adult populations. Preventable adverse events, which accounted for approximately half of all events, were particularly common in children undergoing surgery or requiring intensive care. Diagnostic errors also accounted for a significant proportion of preventable adverse events. A preventable error in a critically ill 8-month-old child is discussed in an AHRQ WebM&M commentary.
Detection and prevention of near misses depend on a balance between individual accountability and collective vigilance, according to interviews with clinicians of different disciplines at an academic medical center.
Sinkowitz-Cochran R, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-43.
The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.