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.
Etheridge JC, Moyal-Smith R, Yong TT, et al. JAMA Surg. 2023;Epub Nov 15.
Surgical safety checklists have been credited with improving perioperative patient outcomes, but numerous studies have shown implementation to be variable across settings and surgical specialties. This study aimed to redesign and reimplement the surgical safety checklist in two academic hospitals. Item completion and fidelity improved after reimplementation and exploratory analysis suggests improved patient outcomes (e.g., serious complications).
Moyal-Smith R, Etheridge JC, Turley N, et al. BMJ Qual Saf. 2023;Epub Sep 21.
Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.
Fortis B, Bell L. Pro Publica. September 12, 2023.
Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.
Gillette C, Perry CJ, Ferreri SP, et al. J Physician Assist Educ. 2023;34:231-234.
A study conducted in 2011 concluded that pharmacy students identified more prescribing errors than their medical or nursing counterparts. This study replicates the 2011 study with first- and second-year physician assistant (PA) students. The results suggest PA students, regardless of year, identified prescribing errors at similar rates to medical and nursing students, although identification rates were low for all three student groups.
Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.
Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.
Structural racism and implicit biases can lead to poor quality of care and adverse outcomes among Black women. This article describes the experience of a Black OB/GYN patient whose concerns about abdominal pain during her pregnancy were not thoroughly evaluated; clinicians also missed risk factors placing her at risk of spontaneous preterm birth.
Bell T, Sprajcer M, Flenady T, et al. J Clin Nurs. 2023;32:5445-5460.
Fatigue is a known contributor to adverse events and near misses. Researchers summarized 38 studies on the impact of fatigue on nurses’ medication administration errors (MAE) or near misses. Thirty-one studies reported that long hours, shift work, overtime, and/or poor sleep quality contributed to MAE and near miss, but results and methods of measuring fatigue were inconsistent.
Bell SK, Dong ZJ, DesRoches CM, et al. J Am Med Inform Assoc. 2023;30:692-702.
Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.
Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.
Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.
McDade JE, Olszewski AE, Qu P, et al. Front Pediatr. 2022;10:872060.
Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.
Salema N-E, Bell BG, Marsden K, et al. BJGP Open. 2022;6:BJGPO.2021.0231.
Medication prescribing errors are common, particularly during medical training. This retrospective review of prescriptions from ten general practitioners in training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed) and suboptimal prescribing (35%).
Luty JT, Oldham H, Smeraglio A, et al. Acad Med. 2022;97:529-535.
Improving student and resident education and involvement in quality improvement and patient safety is a goal of graduate medical education. Researchers at Oregon Health & Science University developed a simulation-based medical education curriculum for multidisciplinary residents and fellows. The pilot cohort reported significantly improved reactions, attitudes and confidence, and knowledge and skills.
Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.
Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Int J Surg. 2022;98:106210.
Non-technical skills such as communication, teamwork, decision-making, and situational awareness are responsible for a significant proportion of surgical errors. The COVID-19 pandemic increased the stress in the operating room, associated with increased risk of exposure and shortage of resources. This study compared pre- and post-COVID direct observations during live operations and found that non-technical skills were equivalent; there was a small, but statistically significant, improvement in teamwork and cooperation skills.
Bell SK, Dong J, Ngo L, et al. BMJ Qual Saf. 2023;32:644-654.
Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.
Ottosen MJ, Sedlock E, Aigbe AO, et al. J Patient Saf. 2021;17:e1145-e1151.
This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2022;31:526-540.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.
Bulliard J‐L, Beau A‐B, Njor S, et al. Int J Cancer. 2021;149:846-853.
Overdiagnosis of breast cancer and the resulting overtreatment can cause physical, emotional, and financial harm to patients. Analysis of observational data and modelling indicates overdiagnosis accounts for less than 10% of invasive breast cancer in patients aged 50-69. Understanding rates of overdiagnosis can assist in ascertaining the net benefit of breast cancer screening.
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.