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.
Medication administration is a complex process and prone to errors. This review was conducted to identify predictors and incidence of medication administration errors (MAE) in African hospitals. Most predictors were at the system level (e.g., work environment, interruptions), followed by patient and professional/provider factors. As the number of included studies was low (13 studies) and most came from one nation, additional studies are needed.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.
Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8:639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.
Lake ET, Roberts KE, Agosto PD, et al. J Patient Saf. 2021;17:e1546-e1552.
The nursing work environment affects patient safety. This cross-sectional study surveyed nearly 2000 pediatric acute care nurses about their work environment and safety culture. Researchers measured the hospital work environment using a validated scale, and they assessed safety using the AHRQ Survey on Patient Safety Culture. A culture of blame and fear of speaking up remained prevalent among nurses participating in this survey. As with prior studies, investigators found an association between a high-functioning work environment and positive safety culture. The authors recommend enhancing pediatric acute care work environments for nurses in order to improve patient safety. A previous PSNet interview discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Sloane DM, Smith HL, McHugh MD, et al. Med Care. 2018;56:1001-1008.
Prior research suggests that improved nursing resources may be associated with decreased mortality and adverse events. However, less is known about how changes to nursing resources in the inpatient setting may affect quality and safety over time. In this study involving 737 hospitals and survey data from nurses obtained in 2006 and 2016, researchers found that after adjusting for numerous factors, better nursing resources in terms of work environment, staffing, and education was associated with improvement in quality and patient safety outcomes. A PSNet perspective discussed the impact of nursing resources on patient safety.
Aiken LH, Sloane DM, Barnes H, et al. Health Aff (Millwood). 2018;37:1744-1751.
Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Carthon MB, Hatfield L, Plover C, et al. J Nurs Care Qual. 2019;34:40-46.
This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
… for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios. … Ball JE, Bruyneel L, Aiken LH, et al. Post-operative mortality, missed care and …
Lake ET, de Cordova PB, Barton S, et al. Hosp Pediatr. 2017;7:378-384.
Missed nursing care is common and has been linked to adverse events. This survey found that more than half of pediatric intensive care unit nurses reported missing care during their prior shift. Higher patient loads and poor working environments were associated with more episodes of missed care, corroborating prior research.
Aiken LH, Sloane DM, Griffiths P, et al. BMJ Qual Saf. 2017;26:559-568.
Researchers analyzed patient discharge data and hospital characteristics, as well as patient and nurse survey data, across adult acute care hospitals in six European countries. After adjusting for hospital and patient variables, they found that hospitals in which nursing care was provided to a greater degree by skilled nurses had lower odds of mortality. The authors argue against replacing professional nurses with nursing assistants and suggest that doing so may compromise patient safety by increasing preventable deaths.
Salge TO, Vera A, Antons D, et al. Health Serv Res. 2016;52:959-983.
Methicillin-resistant Staphylococcus aureus (MRSA) is a known cause of serious hospital-acquired infections. This study analyzed the effect of various hospital organizational factors on the incidence of MRSA bloodstream infections. The investigators concluded that hand hygiene, intensive general cleaning efforts, infection control training, and a safety culture conducive to error reporting are the organizational factors associated with significant decreases in MRSA infections.
Lake ET, Hallowell SG, Kutney-Lee A, et al. J Nurs Care Qual. 2016;31:24-32.
This survey of nurses found that those who rated their work environment as poor were more likely to report quality and safety problems, underscoring the well-described link between nurses' working conditions and patient safety. Improving nurse working conditions is a patient safety strategy.
Carthon MB, Lasater KB, Sloane DM, et al. BMJ Qual Saf. 2015;24:255-263.
… focus of patient safety efforts, due to Medicare's payment policy. This cross-sectional study sought to assess … subsequent readmissions are warranted. A recent AHRQ WebM&M perspective discusses the nursing workforce and patient safety. … Carthon JM, Lasater KB, Sloane DM, Kutney-Lee A. The quality of hospital work …
Griffiths P, Dall'Ora C, Simon M, et al. Med Care. 2014;52:975-981.
… ratios may contribute to burnout . A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of … nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse …
Ausserhofer D, Zander B, Busse R, et al. BMJ Qual Saf. 2014;23:126-35.
Nurses are frequently forced to prioritize tasks during busy shifts, leading to some nursing care being left undone. In this multinational European study, nurses most frequently omitted time-intensive but critical practices such as talking with, educating, and providing comfort for patients.