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.
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.
Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.
Manaseki-Holland S, Lilford RJ, Te AP, et al. Milbank Q. 2019;97:228-284.
Measuring patient safety remains an ongoing challenge. This systematic review examined whether preventable death rates could be used as a measure of hospital quality. Researchers reviewed 23 studies and found that estimates of preventable in-hospital death are consistently low. Ascertainment of preventability was not consistent across multiple clinician-reviewers, and the authors estimate that cases would need review by eight or more clinicians to achieve the precision required. The authors conclude that preventable death rates would not be a valid or reliable measure of patient safety. A past PSNet interview discussed the development of hospital standardized mortality ratios and their role in monitoring performance.
Litchfield I, Gill P, Avery T, et al. BMC Fam Pract. 2018;19:72.
Researchers implemented a multicomponent patient safety toolkit designed to help outpatient practices in England provide safer care. They subsequently interviewed staff to better understand their perspective regarding the toolkit's value as well as barriers to its use.
Aldridge C, Bion J, Boyal A, et al. Lancet. 2016;388:178-86.
In-hospital mortality for many conditions is higher on the weekends than on weekdays—a phenomenon known as the weekend effect. Some hypothesize lower specialty physician staffing levels on weekends explains the mortality difference. This cross-sectional study compared specialist staffing levels and mortality rates at 115 hospitals in the English National Health Service on Sundays compared to Wednesdays. Researchers found a higher mortality rate and lower intensity of specialty services on weekends, but there was no correlation between the two ratios. Although this study is not definitive, it does imply that alternate mechanisms may explain the weekend effect, such as case mix differences, variation in nonphysician staffing, or lower availability of diagnostic services. A previous PSNet interview discussed the weekend effect in health care.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. BMJ Qual Saf. 2017;26:408-416.
Ascertaining whether adverse events are preventable is a continuing challenge in patient safety. Comparing two scales that assess preventability for mortality, this study found that there is high variability among experts rating the preventability of the same mortality event. These results suggest that preventability remains subjective despite attempts to define it in a reproducible fashion.
Litchfield I, Bentham L, Hill A, et al. BMJ Qual Saf. 2015;24:681-90.
This telephone survey of outpatient practice managers in the United Kingdom found that most practices expected patients to inquire about their test results, in line with prior research. The vast majority of respondents did not have systems in place to ensure that laboratory results were received and acted upon. This underscores the persistence of test results management as a safety vulnerability despite extensive research.
Litchfield I, Bentham L, Lilford RJ, et al. BMJ Qual Saf. 2015;24:691-9.
Failure to appropriately communicate test results is a recognized safety hazard in ambulatory care. Despite more than a decade of research into this problem, this survey of 50 general practices in the United Kingdom found that 80% required patients to call to find out their test results, and a similar proportion had no fail-safe mechanism for tracking test results.
Litchfield I, Bentham L, Lilford RJ, et al. Fam Pract. 2014;31:592-7.
The communication of test results is a key activity for primary care practices. However, this qualitative study discovered that current systems for communicating test results vary widely across practices and pose many crucial pitfalls, such as the lack of a method for detecting delayed or missing results.
Shekelle PG, Pronovost P, Wachter R, et al. Ann Intern Med. 2013;158:365-8.
Progress in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor understanding of how context influences safety strategies, and insufficient information on how best to implement evidence-based safety strategies. The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, which culminated in the release of the Making Health Care Safer II report. Detailing methodology that the report's authors used to systematically review the evidence on effectiveness, context, and implementation for 41 key safety strategies, this commentary presents 10 strategies considered ready for widespread implementation. These strategies—including checklists to prevent certain health care–associated infections and surgical complications, bundled interventions to reduce falls and pressure ulcers, and interventions to decrease medication errors and improve hand hygiene—are all considered to have strong evidence of effectiveness, minimal potential for adverse consequences, and be reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal Medicine.
Yao GL, Novielli N, Manaseki-Holland S, et al. BMJ Qual Saf. 2012;21 Suppl 1:i29-38.
Using the example of an initiative to prevent adverse events after hospital discharge, this study presents a framework for estimating the cost effectiveness of proposed interventions to improve patient safety.
This Bayesian analysis of results from the PINCER trial—a pharmacist-led information technology intervention to reduce medication errors in primary care—estimates the likelihood that the intervention would prevent certain adverse drug events.
Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.
Hard stop alerts within computerized provider order entry (CPOE) systems are intended to avert serious medication errors by preventing prescribing of contraindicated medications. This study investigated whether data from a CPOE system could be used to identify individual physicians who commit more frequent prescribing errors. However, the study found that trainee physicians who committed errors prompting hard stop alerts were not more likely to commit less serious prescribing errors, nor did they appear to ignore prescribing warnings more frequently. Although objective performance data would help identify doctors who frequently make prescribing errors, this study's results indicate that triggering of CPOE alerts is not a reliable measure.
Shekelle PG, Pronovost P, Wachter R, et al. Ann Intern Med. 2011;154:693-6.
Research on patient safety has dramatically increased in the past decade, but despite this, the progress of improving safety remains slow. Significant controversy exists about how safety interventions should be evaluated, and even apparently successful interventions may not be generalizable to all settings. This AHRQ-sponsored consensus statement by leaders in the safety field defines a framework for rigorous assessment of safety interventions. This framework calls for investigators to use change theory to develop their projects; provide adequate details of the intervention, implementation process, and the context in which the intervention was conducted; and evaluate both the expected outcomes and potential unintended consequences of the intervention. The accompanying editorial (see link below) discusses the challenges of conducting research in complex settings, and takes note of existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.
Benning A, Dixon-Woods M, Nwulu U, et al. BMJ. 2011;342:d199.
This study is the second phase of the United Kingdom's Safer Patients Initiative (SPI), a large-scale effort to improve patient safety through multifaceted interventions and an independent evaluation. Similar to the first phase study, this one demonstrated little added benefit of SPI on key safety outcomes in 20 hospitals, though overall safety did improve. An accompanying editorial [see link below] discusses the study findings and emphasizes the continued need to run toward science rather than away from it in evaluating quality improvement efforts.