Skip to main content

The PSNet Collection: All Content

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.

Search All Content

Search Tips
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Search By Author(s)
PSNet Original Content
Commonly Searched Resource Types
Additional Filters
Displaying 1 - 16 of 16 Results
Sherwood R, Bismark M. BMJ Qual Saf. 2020;29:113-121.
Confidential skill assessments have been recommended as a strategy to ensure competence among aging surgeons. In this qualitative study, the authors describe opinions from 52 experts on how to manage potential concerns associated with aging surgeons.
Moore JS, Mello MM, Bismark M. Bioethics. 2019;33:948-957.
Patient engagement is now acknowledged as a cornerstone of patient safety, but the perspectives of patients who have experienced adverse events remain understudied. This interview study of 92 patients who had experienced iatrogenic injury identified several insights about the aftermath of adverse events. As with prior studies, researchers found that patients expressed a desire to be heard. Participants had positive perceptions of patient safety research and expressed a desire that others learn from the adverse event they experienced. The authors suggest that institutional review boards permit investigators to approach patients who have experienced adverse events to participate in studies, rather than prohibit such studies due to fear of causing further psychological harm. They also recommend that researchers discuss these adverse events with patients through a reciprocal lens, expressing support and sympathy rather than maintaining an emotionally distant stance. A previous PSNet interview with the lead author discussed disclosure and apology in health care.
Moore J, Bismark M, Mello MM. JAMA Intern Med. 2017;177:1595-1603.
Communication-and-resolution programs have demonstrated declines in malpractice claims in early studies, but implementing these programs effectively has been a challenge. This study is the first to examine patient perspectives on communication-and-resolution programs. Investigators interviewed 30 patients, most of whom experienced harm. Respondents expressed a desire for providers to listen to their perspectives without interruptions, consistent with prior studies. Although patients wished for information regarding what hospitals planned to do to prevent similar events in the future, most reported that they did not receive such follow-up. The authors state that their findings represent opportunities to improve communication-and-resolution programs. A past PSNet interview discussed an organization's pioneering efforts to implement a communication-and-response system.
WebM&M Case September 1, 2016
Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
Studdert DM, Bismark M, Mello MM, et al. New Engl J Med. 2016;374:354-362.
A growing body of research has begun to assess the role of individual clinicians in patient safety, seeking to identify clinicians whose patients are at elevated risk of adverse events. Examining data on paid malpractice claims from the National Practitioner Data Bank over a 10-year period, this study found that 1% of physicians accounted for 32% of paid claims. Moreover, recidivism was common, in that practitioners with more than 3 claims had a 24% risk of another claim within the next 2 years. As in prior studies of malpractice data, surgeons and obstetricians were more likely to have paid a claim than internists. The pattern of a relatively small number of physicians incurring repeated claims, which mirrors data from studies of patient complaints, implies that it may be possible to identify clinicians who are at high risk of subsequent malpractice claims or patient complaints. The issues around such high-risk physicians are discussed in a previous WebM&M perspective.
Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-61.
Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.
Spittal MJ, Bismark M, Studdert DM. BMJ Qual Saf. 2015;24:360-8.
Past studies have found a correlation between patient complaints and patient safety problems. Researchers sought to identify physicians at highest risk for a second patient complaint using routinely collected administrative data. They developed a risk prediction model which predicted future complaints with reasonable accuracy. Factors such as procedural specialty, male gender, and time since prior complaint were associated with a subsequent patient complaint. Application of this model has the potential to allow real-time identification of physicians at risk for further patient complaints and possible litigation. Actions to reduce future litigation risk—such as directed education, referral to a regulatory agency, or notification of the risk of future complaints—could be appropriately targeted based on this prediction model. A related editorial urges prompt and rigorous investigation of patient complaints.
Bismark M, Studdert DM. BMJ Qual Saf. 2014;23:474-82.
This qualitative study found that most health care leaders believe that board members have opportunities to influence quality and safety. However, insufficient knowledge, experience, and performance measurement may hinder board engagement in quality and safety, and these barriers may contribute to deficiencies in performance.
Wu AW, McCay L, Levinson W, et al. J Patient Saf. 2017;13:43-49.
Based on a series of international expert meetings, this qualitative analysis identified key challenges in error disclosure: policy implementation, patient expectations, confidentiality and legal privilege, aligning disclosure with liability, and documenting and tracking disclosure. These barriers suggest that multiple actions are needed to bolster disclosure efforts. The authors advocate for collaboration between health systems and policymakers, enhanced patient and provider education to foster a blame-free safety culture, and establishment of standard metrics to document and benchmark disclosure across institutions. In a past AHRQ WebM&M perspective, Dr. Albert Wu discussed the importance of disclosing adverse events.
Bismark M, Spittal MJ, Gurrin LC, et al. BMJ Qual Saf. 2013;22:532-40.
Although most patient safety efforts focus on identifying and addressing flawed systems, individual clinicians who cause recurrent problems—either through substandard clinical performance or overtly disruptive behavior—must be addressed as well. This analysis of an Australian national database revealed that just 3% of physicians accounted for nearly half of all complaints filed by patients, and relatively simple characteristics (including physician gender, clinical specialty, and number of prior complaints) predicted the likelihood that an individual clinician would be the subject of future complaints. These data, combined with prior research connecting medical school behavior to the risk of future disciplinary action, provide a means for regulatory authorities to predict problematic behavior by clinicians and point the way toward system-level solutions for problem doctors.