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.
Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.
Weaver MD, Sullivan JP, Landrigan CP, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 7.
The Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours have improved resident well-being, but the impact on education, clinical and patient safety outcomes is less clear. This meta-analysis found that the 2003 ACGME restrictions (limiting residents to 80-hour work weeks and 28-hour shifts) was associated with an 11% reduction in mortality; however, there was no significant difference in mortality after the 2011 restrictions (limiting first-year residents to 16-hour shifts). These findings reinforce the impact of extended resident physician work hours and patient morbidity and mortality. The authors also recommend that future research examine the relationship between work hours and patient outcomes among other health care workers.
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;Epub May 29.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
The Accreditation Council for Graduate Medical Education (ACGME) in the United States limits resident physicians' workweek to 80 hours. Several studies have investigated the association between first year residents (i.e., interns, PGY1), worked hours and patient safety. This study includes residents beyond the first year (i.e., PGY2+). Nearly 5,000 PGY2+ residents reported the number of hours worked, patient safety outcomes, and resident health and outcomes. Working more than 60 hours in a week significantly increased the risk of a medical error resulting in patient death. The authors suggest weekly workweek limits should be significantly reduced, such as they are in the United Kingdom.
Quan SF, Landrigan CP, Barger LK, et al. J Clin Sleep Med. 2023;19:673-683.
Fatigue and sleep deprivation among healthcare workers can increase the risk of errors. This prospective study including 60 attending surgeons from departments of surgery or obstetrics and gynecology at eight hospitals found that sleep deficiency was not associated with greater numbers of errors during procedures performed the next day. However, non-technical skill performance, situational awareness, and decision making were adversely associated with sleep deficiency.
Kuzma N, Khan A, Rickey L, et al. J Hosp Med. 2023;8:316-320.
I-PASS, a structured hand-off tool, can reduce preventable adverse events during transitions of care. Previously published studies have shown that Patient and Family-Centered (PFC) I-PASS rounds reduced preventable and non-preventable adverse events (AE) in hospitalized children. This study presents additional analysis, comparing AE rates in children with complex chronic conditions (CCC) to those without. Results show a reduction in AE in both groups, with no statistically significant differences between the groups, suggesting PFC I-PASS may be generalizable to broader groups of patients without needing modification.
Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.
Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.
Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.
Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Weaver MD, Landrigan CP, Sullivan JP, et al. BMJ Qual Saf. 2023;32:81-89.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) introduced a 16-hour shift limit for first-year residents. Recent studies found that these duty hour requirements did not yield significant differences in patient outcomes and the ACGME eliminated the shift limit for first-year residents in 2017. To assess the impact of work-hour limits on medical errors, this study prospectively followed two cohorts of resident physicians matched into US residency programs before (2002-2007) and after (2014-2016) the introduction of the work-hour limits. After adjustment for potential confounders, the work-hour limit was associated with decreased risk of resident-reported significant medical errors (32% risk reduction), reported preventable adverse events (34% risk reduction), and reported medical errors resulting in patient death (63% risk reduction).
Humphrey KE, Sundberg M, Milliren CE, et al. J Patient Saf. 2022;18:130-137.
Poor provider-provider and provider-patient communication can result in significant morbidity and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures identified in nearly half. Of the communication errors that involved a failed handoff (47%), the majority could have potentially been prevented with a structured handoff tool.
Rahman SA, Sullivan JP, Barger LK, et al. Pediatrics. 2021;147:e2020009936.
Reducing resident shift duration can improve resident health and patient safety. This study found that resident shifts limited to 16 hours can reduce performance impairment and medical errors, compared to extended work shifts (24+hours).
Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.
Khan A, Yin HS, Brach C, et al. JAMA Pediatr. 2020;174:e203215.
Language barriers between patients and providers is a potential contributor to adverse events. Based on a cohort of 1,666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspeciality patients 17 years and younger, this study examined the association between parents with limited comfort with English (LCE) and adverse events in hospitalized children. Compared with children of parents who expressed comfort or proficiency with English, children of parents who expressed LCE had significantly higher odds of experiencing an adverse event, including preventable events. Future research should focus on strategies to improve communication and safety for this vulnerable group of children.
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382:2514-2523.
This article presents longitudinal follow-up of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, which examined the effects of flexible duty-hour policies on resident outcomes. After four years, there was no evidence of increased duty-hour violations, decreased satisfaction or decreased well-being among residents randomized to flexible duty-hour policies. The researchers also observed that the beneficial impacts of flexible duty-hours persisted over the four-year period, whereas most of the negative effects diminished over time.
Barger LK, Sullivan JP, Blackwell T, et al. Sleep. 2019;42.
In this clustered-randomized trial across six academic medical centers, researchers examined the impact of resident shift duration on hours slept and worked per week during pediatric intensive care unit rotations. They found that residents assigned to extended duration shifts lasting 24 hours or longer worked more hours per week and slept fewer hours per week compared to residents assigned to work shifts lasting 16 hours or shorter.