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.
Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;31:255-258.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.
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.
Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29:971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.
… at the time by pioneering safety and quality expert Dr. John Eisenberg, prioritized this need by funding the … the 20 key resources. Our PSNet clinician editors are SumantRanji, Kiran Gupta, Urmimala Sarkar, Audrey Lyndon, … San Francisco … Sumant … Robert … Ranji … Wachter … R … SumantRRanji … RobertWachter …
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
… and—probably most importantly—making the economics work. … RobertM. Wachter, MD … Professor and Chair, Department of Medicine …
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
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.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.
Auerbach AD, Neinstein A, Khanna R. Ann Intern Med. 2018;168:733-734.
Digital tools have the potential to improve diagnosis, patient self-care, and patient–clinician communication. This commentary argues that digital tools that alter diagnosis or treatment require examination to ensure safety. The authors provide recommendations such as involving experts in evaluating the tools, engaging information technologists, and continuous local review and assessment to identify and address risks associated with use of such tools in practice.
Shaikh U, Afsar-Manesh N, Amin AN, et al. Int J Qual Health Care. 2017;29:735-739.
Health care institutions are increasingly focused on teaching quality improvement and patient safety to both faculty and trainees. This study describes the implementation of an online course comprised of three quizzes to teach important concepts related to quality improvement, patient safety, and care transitions across five academic medical centers.
Sarkar U, McDonald KM, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.
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.
… competency—be addressed in equally innovative ways. … RobertM. Wachter, MD … Professor and Chair, Department of … 2010;112:985-992. [go to PubMed] 7. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a … do about training and certification of surgeons? … KB … : John Birkmeyer's study was brilliant. The fact that technical …
This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Narayana S, Rajkomar A, Harrison JD, et al. J Grad Med Educ. 2017;9:627-633.
Insufficient follow-up with patients after hospitalization hinders identification of diagnostic or treatment errors. This commentary discusses the results of an intervention that incorporated a structured process for residents to gather information and reflect on patient status for postdischarge follow-up.
Duong JA, Jensen TP, Morduchowicz S, et al. J Gen Intern Med. 2017;32:654-659.
Patients hospitalized and cared for by an overnight physician, known as "holdover admissions," are increasingly common due to duty hours limitations, and they necessitate handoffs between admitting physicians and the new primary medical team. This qualitative study identified unmet needs in holdover handoffs, including assessment of diagnostic uncertainty, standardization, and feedback. The authors call for more scrutiny of holdover handoffs.
Burke RE, Schnipper JL, Williams M, et al. Med Care. 2017;55:285-290.
This retrospective cohort study demonstrated that a readmission risk score could prospectively identify patients at risk for readmissions for the four target conditions for nonpayment: acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure. These results suggest that this algorithm can identify a high-risk patient group who may benefit from interventions to prevent readmission.
Pincavage A, Donnelly MJ, Young JQ, et al. Jt Comm J Qual Patient Saf. 2017;43:71-79.
Year-end handoffs in residency training settings are a known patient safety risk. This narrative review found that several practices can enhance the safety of year-end transitions, including standardizing written and verbal signout for high-risk patients and enhancing attending-level supervision.