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.
Sokol-Hessner L, Folcarelli P, Annas CL, et al. Jt Comm J Qual Patient Saf. 2018;44:463-476.
… and preventing emotional harm. Researchers convened a multidisciplinary expert group to identify best practices … patients , and supporting frontline staff. They provide a list of practical tactics to shift health care organizations toward a more respectful and just culture . A PSNet perspective …
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
Schiff G, Nieva HR, Griswold P, et al. Med Care. 2017;55:797-805.
… Medical care … Med Care … A recent AHRQ technical brief on ambulatory safety found that … controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety … that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and …
Schiff G, Nieva HR, Griswold P, et al. Health Serv Res. 2016;51 Suppl 3:2634-2641.
… Research and Quality, the PROMISES project involved a multipronged intervention within 16 randomly selected … medication management, and communication issues. A previous PSNet perspective discussed how research may help …
Singer SJ, Nieva HR, Brede N, et al. Med Care. 2015;53:141-52.
… and existing safety processes. Administrators reported a lack of safety systems, consistent with prior discussion of … to manage their workload leads to safety problems, echoing a recent focus group study of physicians. Respondents also … opportunities to improve safety in primary care settings. A recent AHRQ WebM&M interview and perspective discuss …
Shahian DM, Wolf RE, Iezzoni LI, et al. N Engl J Med. 2010;363:2530-9.
Hospital-wide mortality rates are widely used as a marker of health care quality, but it remains unclear how to most accurately measure them. In this classic study, investigators provided standard hospital discharge data to four vendors who independently calculated hospital mortality rates. These methods produced varying rates of hospital mortality, and classification of hospitals as either higher or lower than average differed depending on the estimation method. These findings demonstrate that in-hospital mortality remains difficult to estimate and underscore the need for caution in considering it a marker of hospital care quality.
Schiff G, Griswold P, Ellis BR, et al. Jt Comm J Qual Patient Saf. 2014;40:91-96.
This commentary describes the partnerships and consensus efforts involved in the PROMISES Project to promote communication and support error disclosure in the ambulatory setting. The authors review a plan to disseminate and assess the impact of the initiative and its associated tools.
Classen D, Resar RK, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.
Despite numerous studies over the past three decades, one fundamental patient safety question remains controversial: what proportion of hospitalized patients are harmed by medical care? Prior estimates range from approximately 3% to nearly 17%, but this study found that nearly one-third of patients experienced an adverse event during hospitalization. This study used the Institute for Healthcare Improvement's Global Trigger Tool to detect adverse events and also found that this trigger tool identified significantly more adverse events than voluntary reporting or the AHRQ Patient Safety Indicators. An important caveat is that this study did not assess whether the adverse events detected were preventable. Nevertheless, the results do raise the concern that adverse events remain common despite enhanced safety efforts. The challenges of accurately measuring patient safety events were discussed in an AHRQ WebM&M perspective.
Sharek PJ, McClead RE, Taketomo C, et al. Pediatrics. 2008;122:e861-e866.
This AHRQ-funded study describes the implementation of an Institute for Healthcare Improvement–style quality improvement collaborative aimed at reducing narcotic-related adverse drug events (ADEs). Fourteen participating hospitals adopted a series of recommended interventions while tracking ADE rates in a pre- and postintervention study design. Investigators discovered a 67% reduction in narcotic-related ADE rates, and also noted decreased rates of constipation and automated drug-dispensing overrides in patients receiving narcotic therapy. The authors point out several limitations to the study, including the inability to measure compliance with the intended change packages at each hospital. This study provides a nice example of the challenges in evaluating multifaceted quality improvement interventions despite its successful outcomes.
Fowler FJ, Epstein AM, Weingart SN, et al. Jt Comm J Qual Patient Saf. 2008;34:583-90.
… most of these resulted in significant health consequences. A growing body of literature shows that patient surveys are … events, and involving patients in safety efforts is a key component of providing patient-centered care . …
Weissman JS, Schneider EC, Weingart SN, et al. Ann Intern Med. 2008;149:100-108.
While many methods exist for detecting inpatient adverse events, ranging from medical record review to incident reporting, no single method is considered optimal. Patient involvement in safety efforts is being actively promoted, but current efforts have focused on empowering patients to help prevent errors. This study attempted to detect adverse events by surveying patients recently discharged from the hospital, and compared patients' reports with review of their medical records. Patients reported multiple preventable errors that were not identified in medical record review, as well as additional adverse events that occurred after discharge. The concern that patients may not be able to differentiate between poor service quality and adverse events was not borne out in this study. The authors recommend that hospitals consider adding questions about adverse events to existing patient satisfaction surveys.
Fischer M, Mazor KM, Baril JL, et al. J Gen Intern Med. 2006;21:419-23.
… may promote improved learning from errors for trainees. A past study discussed one of these methods, Morbidity and Mortality Conferences, as a place to discuss medical errors with an educational focus. …
Gandhi TK, Bartel SB, Shulman LN, et al. Cancer. 2005;104.
Chemotherapeutic drugs share the characteristic of providing life-saving benefits at the expense of substantial toxicity if not administered and monitored carefully. With ongoing advances in such therapy and a growing shift to outpatient treatment in infusion clinics, this prospective cohort study evaluated more than 10,000 medication orders at a cancer institute in both adult and pediatric settings. Investigators discovered an overall error rate of 3%, with the majority of errors deemed to have a potential for harm. Most of the errors never reached the patient as nurses and pharmacists caught them before administration. Of note, the reported error rate of 3% was lower than past studies in inpatient (5%) and outpatient settings (8%). The authors conclude by sharing the prevention strategies that came from their local findings and how the complexity of outpatient oncology treatment warrants ongoing attention.
… medication errors and harm. … Case & Commentary: Part 1 … A 68-year-old man with a history of diabetes and atrial … solutions (eg, forms) rather than computers. … FrankFederico, RPh … Director, Institute for Healthcare …
Gandhi TK, Weingart SN, Seger AC, et al. J Gen Intern Med. 2005;20:837-841.
This prospective cohort study looked at prescribing errors in four adult primary care practices where both handwritten and basic electronic prescription support were used. Eight percent of prescriptions had an error. Practices with only "basic" computer support (such as no or optional allergy and drug interaction checks) were no safer than those with handwritten prescriptions. More advanced decision support (i.e., requiring complete prescriptions and providing default dosing and frequencies) could have prevented most errors.
Hanna D, Griswold P, Leape L, et al. Jt Comm J Qual Patient Saf. 2005;31:68-80.
… and patient safety … Jt Comm J Qual Patient Saf … Part of a special theme issue on Communicating Critical Test Results, this article outlines a series of safe practice recommendations, building on an … provide context to their recommendations and then offer a detailed table that walks users the suggested practices. …