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.
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Cribb A, O'Hara JK, Waring J. BMJ Qual Saf. 2022;31:327-330.
Patient safety advocates recommend a shift from a blame culture to a just culture. This commentary describes three types of justice that exist in healthcare - retributive, no blame or qualified blame, and restorative. The authors invite debate around the concept of just culture and its role in the “real world”.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24:185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).
Keen J, Abdulwahid MA, King N, et al. BMJ Open. 2020;10:e036608.
Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.
Scott J, Dawson P, Heavey E, et al. J Patient Saf. 2021;17:e1744-e1758.
This study reviewed incident reports involving older adult patient transitions in geriatrics, cardiology, orthopedics and stroke to identify the types of transitions involved and whether reports included any evidence of individual or organizational learning. Half of all incident reports involved interunit/department/team transfers and the majority (69%) of incidents were related to pressure injuries, falls, medication, and documentation errors. Few incident reports referenced individual or organizational learning (e.g., team discussions, root cause analysis) to inform practice or policy changes. A prior WebM&M describes a medication error occurring during an intrahospital transfer between the ICU and interventional radiology.
Scott J, Heavey E, Waring J, et al. BMC Health Serv Res. 2019;19:613.
This study reports the results of a survey measuring patients' experience of their own safety during care transitions. The survey data were perceived to be useful to physicians and hospital staff to identify potential safety risks and could be used to inform changes to improve care.
Heavey E, Waring J, De Brún A, et al. J Health Soc Behav. 2019;60:188-203.
Engaging patients effectively to promote safety is considered a best practice and is endorsed by organizations such as The Joint Commission. Yet, how patients perceive the responsibility for achieving safety remains poorly understood. Investigators conducted semistructured interviews with 28 patients who were discharged from the hospital to better understand how they attribute responsibility for their safety in the health care setting. Direct responses revealed that patients consider health care professionals as being primarily responsible for patient safety but that patients also perceive themselves as playing a part. Narrative responses illustrated why professionals or patients might be responsible and in what context or situation one group might bear more responsibility than another. A past Annual Perspective discussed patient engagement in safety.
O'Hara JK, Aase K, Waring J. BMJ Qual Saf. 2019;28:3-6.
Various conditions must be in place to fully enable patient engagement. This commentary suggests that systems and care teams establish adaptable conditions to facilitate communication with patients during care activities to contribute to system resilience and health care safety.
Gartshore E, Waring J, Timmons S. BMC Health Serv Res. 2017;17:752.
Nursing homes and other long-term care facilities struggle with establishing a safety culture. This scoping review sought to assess the status of safety culture and improvement in residential care. Researchers found that the number and rigor of studies available were lacking and none of the studies included insights from the patients and families using the facilities.
De Brún A, Heavey E, Waring J, et al. Health Expect. 2017;20:771-778.
Receipt of safety reports from patients and family is an important aspect of patient engagement. This qualitative research study identified several barriers for patients in reporting safety concerns, including inability to separate safety from overall satisfaction with care, insufficient understanding of how to report concerns, and a perception that patient feedback would not lead to change.
Scott J, Heavey E, Waring J, et al. BMJ Open. 2016;6:e011222.
Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.
Peerally MF, Carr S, Waring J, et al. BMJ Qual Saf. 2017;26:417-422.
Root cause analysis (RCA) is a strategy to investigate incidents that has gained acceptance in health care. Discussing weaknesses associated with using RCAs, this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis quality, and insufficient feedback should be addressed to enhance the effectiveness of RCAs and sustain organizational learning from failure.
Timmons S, Baxendale B, Buttery A, et al. Emerg Med J. 2015;32:368-72.
Human factors approaches have been increasingly applied to patient safety system designs. This study found that frontline emergency department and surgical clinicians regard human factors training as a beneficial experience.
Waring J, Currie G, Crompton A, et al. Soc Sci Med. 2013;98:79-86.
This study explores the different ways that risk managers, risk officers, clinical leaders, and professional executives promote learning about patient safety in their organizations. The findings suggest that hybrid clinical-managers may best contribute to knowledge sharing due to their ability to bridge practice-level staff and organizational leaders.
Nicolini D, Waring J, Mengis J. Soc Sci Med. 2011;73:217-25.
This study explores the tensions between the theory of root cause analysis and its use in practice. While the tool was designed to generate organizational learning, the authors argue that contradictory agendas observed provide an opportunity to reevaluate its application.
This article analyzes the implementation of the United Kingdom's error reporting system, the National Reporting and Learning System, and addresses the cultural conflicts between physicians, nurses, and managers inherent in implementing such a system.