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.
Li E, Lounsbury O, Clarke J, et al. BMC Med Inform Decis Mak. 2023;23:158.
Shortfalls in electronic health record (EHR) interoperability can threaten patient safety. Chief clinical information officers (CCIOs) participating in semi-structured interviews highlighted the ways in which limited EHR interoperability adversely impacts patient health and safety by hindering care coordination and creating inefficient care processes. Participants noted that solutions are necessary at both the technical (e.g., user-centered design) and policy levels.
Barrow E, Lear RA, Morbi A, et al. BMJ Qual Saf. 2023;32:383-393.
Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.
Patient use of digital and online symptom checkers is increasing, but formal validation of these tools is lacking. This systematic review identified ten studies assessing symptom checkers evaluating a variety of conditions, including infectious diseases and ophthalmic conditions. The authors concluded that the diagnostic and triage accuracy of symptom checkers varies and has low accuracy.
Lear R, Freise L, Kybert M, et al. J Med Internet Res. 2022;24:e37226.
As patients increasingly access their electronic health records, they often identify errors requiring correction. This survey of 445 patients in the United Kingdom found that the majority of patients are willing and able to identify and respond to errors in their electronic health records, but information-related and systems-related barriers (e.g., limited understanding of medical terminology, poor information display) disproportionately impact patients with lower digital health literacy or language barriers.
Alboksmaty A, Beaney T, Elkin S, et al. Lancet Digit Health. 2022;4:e279-e289.
The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.
Jones MD, Clarke J, Feather C, et al. Ann Pharmacother. 2021;55:1333-1340.
Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.
Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.
This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.
Denning M, Goh ET, Tan B, et al. PLoS One. 2021;16:e0238666.
This cross-sectional study conducted from March to June 2020 measured anxiety, depression, and burnout in clinicians working in the United Kingdom, Poland, and Singapore. Approximately 70% of respondents reported feeling anxious, depressed and/or burnt out. Burnout was significantly inversely correlated with being tested for COVID-19 and perceiving high levels of safety. These findings highlight the importance of supporting staff well-being and proactive COVID-19 testing.
Freise L, Neves AL, Flott K, et al. JMIR Form Res. 2021;5:e19074.
Patient access to electronic health records (EHRs) can improve health outcomes but is not without concern. This survey of users of a patient portal providing online access to EHRs identified several barriers to understanding information contained in their electronic records, including medical terminology, interpretation of test results, and information display. These barriers signal potential avenues for improving systems providing patient access to their health records.
Denning M, Goh ET, Scott A, et al. Int J Environ Res Public Health. 2020;17:7034.
This study used the Safety Attitudes Questionnaire to evaluate the impact of COVID-19 on safety culture at a large UK teaching hospital compared to baseline scores collected in 2017. Overall, respondents reported more positive perceptions of safety; training and support for redeployment were associated with higher perceptions of safety. However, the analysis identified a significant decrease in error reporting after the onset of the COVID-19 pandemic.
An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.
van Dael J, Reader TW, Gillespie A, et al. BMJ Qual Saf. 2020;29:684-695.
This article reviewed 74 academic and 10 policy resources, as well as interviewed 13 experts, to understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. Findings highlight the need for standardized methods to use and report complaints data, novel policy strategies, and analysis strategies to generate actionable learning insights and translation into quality improvement by affecting leadership and safety culture are discussed.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
McKinney SM, Sieniek M, Godbole V, et al. Nature. 2020;577:89-94.
Research has found that artificial intelligence (AI) can improve diagnostic accuracy, but less is known about its performance in clinical settings. To evaluate the performance of AI in identifying breast cancer in a clinical setting, this study deployed AI in a curated, representative data set from the UK (25,856 women) and an enriched dataset from the US (3,097 women), as well as compared the performance of AI to that of six human radiologist readers. They used biopsy-confirmed cancer patients to evaluate AI predictions. The authors reported a reduction in both false positives and false negatives using AI and found that the AI system was more accurate than the radiologists.
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Archer S, Thibaut BI, Dewa LH, et al. J Psychiatr Ment Health Nurs. 2019;27:211-223.
Researchers conducted focus groups in this qualitative study of staff in mental healthcare settings and assessed the barriers and facilitators to incident reporting. The authors identified unique challenges to incident reporting in mental health, including the incidence of violence and aggressive behavior. Participants often underreported violent or aggressive events because they attributed the behavior to the patient’s diagnosis, and cited dissatisfaction with how reported incidents were handled by police.
Fontana G, Flott K, Dhingra-Kumar N, et al. Lancet. 2019;394:993-995.
This commentary discusses the global state of patient safety, and the role of World Patient Safety Day as a catalyst for patient safety advocacy and improvements. Greater emphasis was placed on patient safety in traditional office settings and the emerging area of telehealth.