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.
Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.
Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.
Lasser EC, Heughan JA-A, Lai AY, et al. Curr Med Res Opin. 2021;37:1991-1999.
… team, including being heard, respected, and treated as a whole person. … Lasser EC, Heughan JA, Lai AY, et al. Patient perceptions of safety in primary care: a qualitative study to inform care. Curr Med Res Opin. Epub …
… coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety … of patient safety practices . … Oberlander T, Scholle SH, Marsteller J, et al. Implementation of patient safety …
Bartholomew AJ, Zeymo A, Chan KS, et al. Ann Surg. 2020;272:612-619.
This study used discharge data from five states to evaluate the impact of the Affordable Care Act’s Medicaid expansion on patient safety outcomes (measured using the PSI 90 composite). Results showed an overall improvement in patient safety in expansion states; however, when expansion states experienced an increase in their safety-net burden, they also experienced significantly more safety events compared to nonexpansion states.
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Rawat N, Yang T, Ali KJ, et al. Crit Care Med. 2017;45:1208-1215.
… infections . This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients … in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the …
Marsteller JA, Hsu Y-J, Chan KS, et al. BMJ Qual Saf. 2017;26:288-295.
The Team Checkup Tool stemmed from work done as part of the Keystone ICU project and is designed to identify barriers to the progress of quality improvement initiatives. In this study, investigators used focus groups and feedback sessions to assess the content of the tool. They conclude that the Team Checkup Tool measures meaningful aspects of team-based quality improvement work.
Marsteller JA, Wen M, Hsu Y-J, et al. Ann Thorac Surg. 2015;100:2182-9.
This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ Hospital Survey on Patient Safety Culture) than other surgical teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this study surgeons reported more optimal safety culture compared to nurses and perfusionists. This gap in perceived safety culture requires further study.
Hsu Y-J, Marsteller JA. Am J Med Qual. 2016;31:349-357.
To determine the impact of the Comprehensive Unit-Based Safety Program (CUSP) on patient safety, this study compared intensive care units participating in the program with units not participating. Although safety culture improved in units with CUSP implementation, the intervention did not reduce incidence of central line–associated bloodstream infections. These findings demonstrate that teamwork training approaches, while helpful, may not be sufficient to augment patient outcomes. Further study characterizing sites that improved versus those that did not may elucidate facilitators and barriers to achieving patient safety goals.
… … J Crit Care … Improving teamwork and communication is a continued focus in the hospital setting. This systematic … perspective describes the Veterans Health Administration's medical team training program. …
Thompson DA, Marsteller JA, Pronovost P, et al. J Patient Saf. 2015;11:143-51.
… of patient safety … J Patient Saf … This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery … surveys, ethnographic direct observation, and analysis of a large database. Safety culture , teamwork and communication …
Berenholtz SM, Lubomski LH, Weeks K, et al. Infect Control Hosp Epidemiol. 2014;35:56-62.
… units (ICUs) stands as one of the patient safety movement's major successes. The initial efforts to prevent CLABSI in … ) and continuous data measurement and feedback, achieved a reduction in CLABSI rates of more than 40%. This remarkable … series of interventions exemplifies the value of using a sociotechnical approach to improving safety and has likely …
In this national survey of attending hospitalists, 40% of respondents reported an unsafe, high workload at least once in the prior month. Physicians working without midlevel assistance or housestaff were more likely to report an unsafe workload, and those working within systems with census control (patient caps, fixed bed capacity, or staff augmentation plans) were less likely to report an unsafe workload.
Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013;28:308-14.
Surgical specimen identification errors occur regularly and preventing misidentification errors is a National Patient Safety Goal. This study reports on an effort to develop process measures for monitoring the quality of specimen identification.
Marsteller JA, Sexton B, Hsu Y-J, et al. Crit Care Med. 2012;40:2933-9.
… in Michigan through use of an evidence-based checklist and a comprehensive unit-based safety program . However, as a pre–post cohort study, it was unable to clearly establish a causal relationship between the intervention and the …
Gurses AP, Kim G, Martinez EA, et al. BMJ Qual Saf. 2012;21:810-8.
Failure to address both operational and cultural factors in cardiac surgery has led to serious safety problems and preventable deaths, most notably at the Bristol Royal Infirmary. This study used detailed observation of cardiac surgical procedures by a multidisciplinary team, including clinicians and human factors engineering specialists, to prospectively identify safety hazards. Many types of hazards were identified, including problems with communication and teamwork, poor interoperability of equipment, and failure to follow established safety protocols. The authors make detailed recommendations to guide institutions in addressing these problems.