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.
Baartmans MC, van Schoten SM, Smit BJ, et al. J Patient Saf. 2023;19:158-165.
Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.
Driesen BEJM, Baartmans M, Merten H, et al. J Patient Saf. 2022;18:342-350.
Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Smits M, Langelaan M, de Groot J, et al. J Patient Saf. 2021;17:282-289.
This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.
Prior research has estimated that 6% of patients receiving medical care experience preventable harm. This study compared the incidence and preventability of adverse events in older patients over an eight-year period (2008-2016). Findings indicate that while the incidence of adverse events declined across the time period, the preventability of the events did not. The authors posit that this could be due to crowding or increasing care complexity due to age, frailty, comorbidities, or polypharmacy.
Silkens MEWM, Arah OA, Wagner C, et al. Acad Med. 2018;93:1374-1380.
Patient safety is an increasing area of focus within graduate medical education. Using data on residency educational climate, patient safety climate, and residents' self-reported patient safety behaviors from 31 teaching hospitals in the Netherlands, researchers found an association between safety climate and self-reported patient safety behavior.
Romijn A, Teunissen PW, de Bruijne M, et al. BMJ Qual Saf. 2018;27:279-286.
This qualitative study assessed perceptions of teamwork and interprofessional collaboration between obstetricians, nurses, and hospital-based and primary care midwives in the Netherlands. Overall, obstetricians perceived teamwork to be better than participants from other disciplines. The gap between physicians, nurses, and midwives was largest with regard to perceived openness to sharing opinions and discussing new ideas.
Merten H, van Galen LS, Wagner C. BMJ. 2017;359:j4328.
Patient handovers between clinical teams are a common point of information exchange that can be challenging to perform due to interruptions, production pressures, and fatigue. This commentary reviews handover behaviors, tools that can enhance handover quality, and how to engage patients and families as information sources during handovers.
van Galen LS, Brabrand M, Cooksley T, et al. BMJ Qual Saf. 2017;26:958-969.
The use of readmission rates as a metric of care quality remains controversial, as United States–based studies have shown that only a minority of readmissions are preventable. This prospective cohort study, conducted in 4 European countries, sought to evaluate the preventability of 30-day readmissions after hospitalization from both clinician and patient perspectives. Investigators found that 27.8% of readmissions were considered predictable (by the majority of those interviewed) and 14.4% were considered preventable. However, there was little consensus between physicians, nurses, patients, and caregivers about whether readmissions were preventable and why readmissions occurred. The only factor that consistently predicted readmission risk was if patients reported not feeling ready to go home on the day of discharge. This study adds to the literature questioning the utility of readmission rates as a measure of the quality of care.
Verbakel NJ, Langelaan M, Verheij TJM, et al. J Patient Saf. 2016;12:152-8.
Most studies of safety culture have focused on hospitals, but the majority of health care takes place in outpatient care. Safety culture in primary care differs from hospital settings. This systematic review was only able to identify two studies, each with significant methodological shortcomings, that examined how to enhance safety culture in primary care. The authors suggest that more intervention studies of safety culture improvement in primary care are needed.
van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.
Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.
Zwijnenberg NC, Hendriks M, Hoogervorst-Schilp J, et al. BMC Health Serv Res. 2016;16:199.
Safety culture is critical to patient safety improvement efforts. According to this survey, health care professionals found that reviewing their own results on the AHRQ Hospital Survey on Patient Safety Culture was useful. However, not all respondents knew what actions they could take to improve safety culture.
Incident reporting systems and root cause analyses remain the main mechanisms by which adverse events are identified and reviewed. This study sought to determine whether more localized, unit-based incident reporting systems might provide better insight into how patient safety incidents vary across hospital units and services than hospital or national level reporting systems. While similar safety issues and root causes were identified across all units and services, medication safety issues were more common on internal medicine and surgical units. On the other hand, collaboration issues were more frequent in emergency medicine units. These findings suggest that localized safety reporting systems might provide information that could promote improvement efforts.
van Rosse F, Suurmond J, Wagner C, et al. BMJ Open. 2016;6:e009052.
This study used interviews with health care providers, patients, and caregivers to explore the safety issues associated with limited language proficiency. Caregivers often had to assume roles (such as interpreting) that had the potential to impair patient safety. A WebM&M commentary discussed a serious medication error arising from a language barrier.
Kemper PF, de Bruijne M, van Dyck C, et al. BMJ Qual Saf. 2016;25:577-87.
This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.
Kristensen S, Hammer A, Bartels P, et al. Int J Qual Health Care. 2015;27:499-506.
In this study, health care organizations that have quality management systems in place had higher safety culture scores than those without such systems. As with prior studies, leaders expressed more positive safety culture than frontline clinicians. This work suggests that ongoing investment in safety culture is needed.
Baines RJ, Langelaan M, de Bruijne M, et al. BMJ Open. 2015;5:e007380.
Comparing adverse event reports from patients who died in the hospital versus patients discharged alive, this chart review study found that preventable adverse events were more likely among those who died. The authors suggest that examining deaths alone does not provide a complete picture of the epidemiology of adverse events and recommend review of multiple outcome types.
Kringos DS, Suñol R, Wagner C, et al. BMC Health Serv Res. 2015;15:277.
The variable success of patient safety interventions has been attributed to the context in which these strategies have been implemented. In this systematic review, researchers found that contextual aspects that influence success of interventions are not systematically examined or reported, hindering understanding of how context affects implementation of patient safety efforts.
Verbakel NJ, Langelaan M, Verheij TJM, et al. Br J Gen Pract. 2015;65:e319-29.
Achieving sustained improvements in safety culture can be difficult. A team-based workshop and facilitated discussion around safety issues resulted in an increase in voluntary incident reporting in primary care clinics in the Netherlands.