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.
Baartmans MC, van Schoten SM, Smit BJ, et al. J Patient Saf. 2023;19:158-165.
Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.
Pavithra A, Mannion R, Sunderland N, et al. J Health Org Manag. 2022;36:245-271.
Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.
Occelli P, Mougeot F, Robelet M, et al. J Patient Saf. 2022;18:415-420.
Understanding patient experience can provide key insights about safety culture. This qualitative study of 80 adult patients concluded that patients’ perspectives of surgical safety are closely tied to the degree of trust they have in their surgeons; this trust is based on the patient’s relationship with their surgeon, communication style, and the patient’s experience during perioperative consultation.
Driesen BEJM, Baartmans M, Merten H, et al. J Patient Saf. 2022;18:342-350.
Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18:e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17:e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
Smits M, Langelaan M, de Groot J, et al. J Patient Saf. 2021;17:282-289.
This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.
Jones A, Blake J, Adams M, et al. Health Policy (New York). 2021;125:375-384.
A key component of patient safety culture is the ability of staff to speak up about patient safety concerns without fear of repercussions. An analysis of 34 studies on speaking-up behavior revealed two narrative themes on why interventions were or were not successful: hierarchical, interdisciplinary, and cultural relationships, and psychological safety. Although interventions varied, there were international similarities in workplace norms and culture. Improving speaking-up behavior in healthcare settings is complex and no intervention is one-size-fits-all.
Prior research has estimated that 6% of patients receiving medical care experience preventable harm. This study compared the incidence and preventability of adverse events in older patients over an eight-year period (2008-2016). Findings indicate that while the incidence of adverse events declined across the time period, the preventability of the events did not. The authors posit that this could be due to crowding or increasing care complexity due to age, frailty, comorbidities, or polypharmacy.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Crit Care Med. 2021;49:e20-e30.
Common nursing procedures, such as bathing patients in their beds, can result in physiologic changes or accidental displacement of medical devices that may be dangerous to the patient. This study of 254 intensive care patients across Western Europe found that serious adverse events occurred in half of patients during bed bathing.
Bion J, Aldridge CP, Girling AJ, et al. BMJ Qual Saf. 2021;30:536-546.
In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.
Alsabri M, Boudi Z, Zoubeidi T, et al. J Patient Saf. 2022;18:e124-e135.
In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.
This literature review assesses the current evidence on medical error prevention and management and explores the integration of patient safety into patient care provided by medical humanitarian organizations. The research identified describes patient safety initiatives occurring within three levels: (1) individual staff involved in care provision or management, (2) medical institutions or organizations, and (3) national healthcare systems, laws and regulations and accreditation bodies. Given the absence of overarching authority over healthcare systems and staff turnover within humanitarian organizations, the authors discuss the importance of adapting patient safety models at the organizational level.
Blenkinsopp J, Snowden N, Mannion R, et al. J Health Org Manag. 2019;33:737-756.
Staff willingness to report threats to patient safety is critical to preventing errors and improving safety and is an indicator of an organization’s safety culture. The authors discuss studies exploring what factors influence whistleblowing, organizational responses, and implications for practice or policy. The authors concluded that the existing literature focuses on the decision to speak up. There is limited evidence discussing organizational responses or systems-level changes, yet these actions influence whether the patient safety threats are addressed and if future events will be reported.
Psychological safety empowers staff to speak up about problems. This commentary highlights how senior managers can help ensure that departmental-level conditions facilitate the reporting of concerns. The authors call for organizations and managers to encourage speaking up and to respond appropriately.
Mannion R, Davies H, Powell M, et al. J Health Organ Manag. 2019;33:221-240.
Organizational acceptance of accountability for failures and implementation of solutions are critical to improve safety. This review explores the impact of investigations focused at the individual, practice, and system levels. The authors describe design and operational failings at each level that enable purposeful or accidental patient harm.
Silkens MEWM, Arah OA, Wagner C, et al. Acad Med. 2018;93:1374-1380.
Patient safety is an increasing area of focus within graduate medical education. Using data on residency educational climate, patient safety climate, and residents' self-reported patient safety behaviors from 31 teaching hospitals in the Netherlands, researchers found an association between safety climate and self-reported patient safety behavior.