Anchoring bias is the tendency to focus on an initial diagnosis despite later evidence to the contrary. This study measured physicians’ potential anchoring bias regarding patients with congestive heart failure (CHF) with shortness of breath presenting to the emergency department. When the patient’s initial triage note included CHF, physicians were less likely and/or slower to test for pulmonary embolism (PE) than when the triage note did not mention CHF. This suggests physicians may have been subject to anchoring bias.

Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.

Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.

… JAMA Netw Open … Fall prevention in healthcare settings is a patient safety priority . This systematic review found that … on fall prevention and management for older adults: a systematic review. JAMA Netw Open. 2021;4(12):e2138911. …

… ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury , … trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care. … Bhasin S, Gill TM, Reuben DB, et al. A randomized trial of a multifactorial strategy to prevent …

… hospitals and only moderate-certainty that alternatives (e.g., video monitoring) can reduce sitter use without … as useful as initially believed. All included studies had a least one methodological limitation (such as not defining what consisted a fall, lack of outcome assessor blinding). … Greeley AM, …

Patient safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the methods and results of an AHRQ Technical Brief, this commentary summarizes expert opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors outline patient safety practices relevant to the ambulatory setting and suggest activities to advance improvement efforts in outpatient care, such as measure development and use of health information technologies.

This systematic review sought to identify a consistently used definition of a high-performing health system. Less than 20% of the included studies defined patient safety as an aspect of high performance. In a related editorial, Dr. Peter Pronovost asserts that inconsistency in defining high performance reflects the need to focus on the purpose of health care in order to achieve transformative improvement.

Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.

This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.

… to this AHRQ-funded systematic review published as part of a patient safety supplement in the Annals of Internal … effect of an intentional change in nurse–patient ratios. … Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review.  Ann Intern …

… Ann. Intern. Med. … Ann Intern Med … Considered a never event for hospitalized patients, falls that result in … approach to fall prevention is discussed in an AHRQ WebM&M perspective . …

… in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor … The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, … reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal …

… Ann Intern Med … This editorial introduces a special supplement of systematic reviews exploring the … field over the past decade. … Wachter RM; Pronovost PJ; Shekelle PG. …

Based on discussions from a 22-person expert panel, this study described four contextual domains judged as important for patient safety practices. The domains included: safety culture, teamwork, and leadership involvement; structural organizational characteristics; external factors (e.g., incentive systems); and availability of implementation and management tools.

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.

The context in which a patient safety intervention is implemented can be as important for success as the strength of the intervention itself. However, this review of five widely accepted patient safety practices found that few specifically evaluated contextual factors during implementation.

This meta-analysis found that interactive communication between collaborating primary care providers and specialists (psychiatrists and endocrinologists in this study) is associated with improved patient outcomes. The interactive communication methods included joint consultations, scheduled phone discussions, and shared documentation, with the authors suggesting a need for changes in reimbursement models to support such interventions.

This study discovered variability in pharmacists' interpretation of physician prescriptions, raising concerns about the consistency of information provided to patients about safe medication use.

This review examined how publicly reported performance data affect quality of care and found that, although releasing such data stimulates quality improvement activities, the impact on clinical outcomes remains unclear.