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.
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.
Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.
Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.
Nether KG, Thomas EJ, Khan A, et al. J Healthc Qual. 2022;44:23-30.
… J Healthc Qual … Medical errors in the neonatal intensive … including healthcare-acquired infection. … Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process … in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1):23-30. …
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.
… J Perinatol … Patients in the neonatal intensive care unit … seven days of admission was 6.2%. … Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the … intensive care unit: a retrospective cohort study. J Perinatol. Epub 2022 Mar 4. doi: 10.1038/s41372-022-01359-9. …
Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;31:255-258.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
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.
Achieving “zero harm” has been advocated as a patient safety goal. This editorial proposes that the conversation shift from striving to achieve absolute safety (Zero Harm) towards actively managing risk using both reactive and proactive approaches to safety management.
Using qualitative methods, this study sought to understand parent perceptions of patient safety in the NICU. The authors present a conceptual model of ‘parents as partners’ in NICU patient safety, emphasizing the importance of clinicians who are present, intentional, and respectful and highlighting factors influencing the parent-clinician partnership, such as communication and teamwork practices.
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.