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.
Lalani M, Wytrykowski S, Hogan H. BMJ Open. 2023;13:e067441.
Care integration —the linking of care across primary, secondary, social, community, and mental health—can improve care for patients with chronic conditions. In this review, 24 studies of integrated care were included. Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home or across settings (e.g., hospital and primary care). The authors recommend future research focus on safety targets beyond falls and medication safety and report on outcomes.
Averill P, Vincent CA, Reen G, et al. Health Expect. 2023;26:51-63.
Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2023;28:50-57.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Rand S, Smith N, Jones K, et al. BMJ Open. 2021;11:e043206.
Care home settings, such as nursing homes or residential care homes, present unique challenges to patient safety. This systematic review identified several gaps in the available safety measures used for quality monitoring and improvement in older adult care homes, including patient experience (e.g., quality of life or other resident-reported indicators of safety), psychological harm related to the care home environment, abusive or neglectful practices, and the absence of processes for integrated learning.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care. In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Wæhle HV, Haugen AS, Wiig S, et al. BMC Health Serv Res. 2020;20.
This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies. Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.
Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.
Haugen AS, Sevdalis N, Søfteland E. Anesthesiology. 2019;131:420-425.
Checklists have been widely embedded into care processes, despite questions regarding their effectiveness in improving safety. This review summarizes the evidence on use of the WHO surgical checklist and highlights the need for persistence, long-term commitment, and implementation strategy to prevent complications.
Edbrooke-Childs J, Hayes J, Sharples E, et al. BMJ Qual Saf. 2018;27:365-372.
Huddles are frequently used in health care to enhance situational awareness. This study describes the development of an observation tool designed to evaluate the effectiveness of team huddles in the inpatient setting.
Weaknesses in error reporting include lack of use, data quality, and reliable feedback. This review describes a framework to better understand the challenges affecting reporting successes. The authors suggest that focusing on organizational, process, and system issues is necessary to design interventions that enhance practitioner use of reporting mechanisms.
Pannick S, Athanasiou T, Long SJ, et al. BMJ Open. 2017;7:e014333.
This prospective trial with concurrent controls examined whether frontline team safety surveillance reduced the instances of longer-than-average length of stay for a given diagnosis. The study team found that incomplete implementation of the intervention actually increased length of stay, whereas stringent implementation of the intervention improved length of stay. The authors conclude that suboptimal implementation can negatively affect safety.
Parand A, Faiella G, Franklin BD, et al. Ergonomics. 2018;61:104-121.
Informal caregivers can make errors in administering medications to patients in home settings. This human factors analysis identified multiple vulnerabilities, including incorrect dosing, storage, timing, and failure to discontinue medications as instructed. The authors note an overall lack of support and communication for caregiver-administered medications in home and community settings.
Frontline providers possess unique insights for improving patient safety and their perceptions may be different from those of managers and clinical leaders. In this qualitative study, researchers sought to harness this expertise and perspective through a multifaceted intervention that involved structured multidisciplinary briefings, increased organizational awareness of challenges identified by frontline providers, and feedback—referred to as prospective clinical team surveillance. They found that the prospective safety intervention created a sense of psychological safety in which team members were more likely to raise concerns without fear of punishment and increased frontline provider engagement in improvement opportunities. The authors emphasize that such an approach provides managers with better insights into issues affecting care delivery. A past PSNet perspective discussed workarounds and resiliency on the front lines of health care.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Howell A-M, Burns EM, Hull L, et al. BMJ Qual Saf. 2017;26:150-163.
Although incident reporting systems remain central to most patient safety programs, they are frequently criticized for their inability to accurately measure harm events and near misses. Researchers interviewed experts to establish consensus on the role of patient safety incident reporting systems. Using a Delphi approach, they were able to derive 40 recommendations. Consistent with prior research, experts agreed that incident reporting systems should not be used to measure rates of harm.
Macdonald AL, Sevdalis N. J Pediatr Surg. 2017;52:504-511.
This systematic review evaluated the patient safety evidence associated with pediatric surgery. Although investigators found sound evidence to support the use of handoff tools, they suggest that further research on interventions to improve safety in pediatric surgery is needed.
Pannick S, Wachter R, Vincent CA, et al. BMJ. 2016;355:i5417.
Patient safety research and commentary often focus on specialized care processes rather than medical wards. Exploring challenges to improving safety in the medical ward environment, this commentary outlines four strategies to address complexity of implementing initiatives in this setting.
Kapur N, Parand A, Soukup T, et al. JRSM Open. 2016;7:2054270415616548.
Applying aviation safety methods in health care settings has received mixed levels of acceptance as a useful approach. This review compares characteristics of aviation and health care, suggests that organizations should consider unique aspects in medicine when developing aviation-based strategies, and notes the benefits of aviation's focus on human factors, teamwork training, and culture to enhance safety.
Pannick S, Sevdalis N, Athanasiou T. BMJ Qual Saf. 2016;25:716-25.
Middle managers have a key role in successful improvement efforts, but engaging them in these activities can be challenging. This narrative review describes a model that involves middle managers and frontline clinicians in multidisciplinary teams to augment implementation of quality improvement interventions.