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.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Patel E, Muthusamy V, Young JQ. Acad Med. 2018;93:898-903.
Physician trainees are required to learn patient safety concepts during residency. This study describes a curriculum that taught psychiatry residents hands-on adverse event analysis skills and culminated in a root cause analysis presentation to hospital safety experts. A past PSNet perspective examined graduate medical education's role in improving safety.
Young JQ, Wachter R, Cate OT, et al. BMJ Qual Saf. 2016;25:66-70.
Implementing standardized handoff processes has garnered attention as a strategy to improve patient safety. In this commentary, the authors apply cognitive load theory to handoff tasks to demonstrate how to improve handover bundles and enhance reliability.
Arbuckle MR, Reardon CL, Young JQ. Acad Psychiatry. 2015;39:132-8.
According to this survey study, a substantial minority of psychiatry residency training programs reported that they did not provide formal training in handoffs, which is now required by the Accreditation Council for Graduate Medical Education. Barriers to developing such training included difficulty attaining buy-in from clinicians and standardizing handoffs across different sites.
Young JQ, Ranji SR, Wachter R, et al. Ann Intern Med. 2011;155:309-15.
The beginning of residency training for new interns has long been rumored to result in preventable harm for patients, a phenomenon known as the "July Effect" in the US and by the more macabre term "August killing season" in the UK. However, prior studies have reached conflicting conclusions about whether the "July Effect" truly exists. This systematic review of 39 studies provides the first comprehensive evidence that being hospitalized in July may actually be harmful, as a subset of larger and higher quality studies did find that mortality increased and efficiency of care decreased in association with new residents assuming their duties. Unfortunately, most studies included in the review had methodological flaws, meaning that the exact degree of harm could not be quantified.
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
Care transitions pose a risk to patient safety. This commentary discusses the problems inherent when patient care responsibilities are transferred from graduating residents to their successors, and suggests methods by which residency programs can ensure safe transitions in this setting.