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.
Rosen MA, Goeschel CA, Che X-X, et al. Simul Healthc. 2015;10:372-377.
Simulation has been used to improve patient safety in multiple settings. This study examines how simulation can enhance safety leadership. Executive leaders in health care organizations were given the simulated task of addressing patient safety failures, with the goal of improving participants' competency in transparency and safety culture. Qualitative analysis demonstrated widely diverging participant responses. There was a lack of leadership engagement with frontline staff around safety. Participants cited leadership walk rounds and committee participation as possible leadership involvement mechanisms. The authors also noted that participants did not consistently engage patients in their safety strategies. Simulation appears to be a promising leadership education strategy that may uncover gaps in current leadership practices. A PSNet perspective explored how leaders can promote cultural changes to improve patient safety.
Sarkar U, Simchowitz B, Bonacum D, et al. Jt Comm J Qual Patient Saf. 2014;40:461-470, AP1.
Diagnostic errors are a common cause of patient harm in ambulatory care. Although such errors have often been ascribed to cognitive biases, this study highlights physicians' concerns that health system structures and communication are major drivers of delayed and missed diagnoses. Focus group discussions involving 25 outpatient physicians—primarily from internal and family medicine—identified multiple potential sources of diagnostic errors, including insufficient information availability, disjointed workflows, and poor communication among providers and with patients. This study underscores many overlapping issues that will need to be addressed to meaningfully enhance diagnostic accuracy. In a recent AHRQ WebM&M interview, Dr. Urmimala Sarkar, the lead author of this study, discussed patient safety in the ambulatory setting.
Sarkar U, Bonacum D, Strull W, et al. BMJ Qual Saf. 2012;21:641-648.
Diagnostic errors have been deemed the "next frontier" in patient safety based on studies suggesting their significant contribution to patient harm. While prevention strategies have focused on the acute care setting, equal concern about diagnostic errors is warranted in primary care practices. This multicenter study surveyed more than 1000 primary care physicians who reported that more than 5% of their patients were difficult to diagnose. Inadequate knowledge was the most commonly reported cognitive factor, with more experienced physicians reporting less diagnostic difficulty. Addressing workload issues, such as panel size and non-visit tasks, was the most common improvement strategy. The authors discuss both system- and practice-level initiatives that may reduce diagnostic difficulties, including allowing more time to process diagnostic information and facilitating better subspecialty input. A past AHRQ WebM&M perspective and interview discuss diagnostic errors.
This publication discusses the plenary session from the 2009 National Patient Safety Congress. A panel of distinguished patient safety leaders, including Drs. Donald Berwick, Carolyn Clancy, Lucian Leape, and Dennis O'Leary, reflected on the impact of To Err Is Human and shared insights on the past and future of safety work.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-85.
Direct observation of teamwork during surgical procedures revealed that poor teamwork was associated with higher rates of postoperative complications and overall mortality, even after adjusting for preoperative risk. Though suboptimal teamwork is a recognized problem in the operating room, this study is one of the first to directly link team behavior to patient outcomes. One method of improving teamwork, crew resource management training, has been extensively evaluated in a variety of clinical settings. A near miss resulting from poor teamwork is illustrated in a recent AHRQ WebM&M commentary.