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.
Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.
Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.
Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17:e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.
Lopez-Pineda A, Gonzalez de Dios J, Guilabert Mora M, et al. Expert Opin Drug Saf. 2021:1-11.
Medication administration errors made by parent or caregivers can result in medication errors at home. This systematic review found that 30% to 80% of pediatric patients experience a medication error at home, and that the risk increases based on characteristics of the caregiver and if a prescription contains more than two drugs.
Mira JJ, Lorenzo S, Carrillo I, et al. Int J Qual Health Care. 2017;29:450-460.
This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.
Mira JJ, Carrillo I, Guilabert M, et al. J Med Internet Res. 2017;19:e203.
Investigators implemented a website in a Spanish health care system that was designed to provide information about the second victim phenomenon and help support those involved. The website was well received by health care professionals and patient safety managers.
Mira JJ, Carrillo I, Fernandez C, et al. JMIR MHealth UHealth. 2016;4:e131.
Health information technology has the potential to facilitate patient safety tasks. This study described the development of a mobile health application for patient safety managers to enable activities such as tracking of risk management processes and safety audits. Users who tested the application reported high satisfaction with the tool, though its efficacy in enhancing safety was not studied.
This qualitative study examined perceptions of nurse and physician quality management leaders about what clinicians experience after being involved in adverse events. Participants acknowledged the emotional impact of adverse events on clinicians and the need for formal mechanisms to offer support to second victims.
Mira JJ, Lorenzo S, Carrillo I, et al. BMC Health Serv Res. 2015;15:341.
This survey of health care organizations found that most reported having inadequate support for second victims. Many organizations lacked protocols for responding to serious adverse events, especially in primary care. These results underscore the importance of implementing safety initiatives to address health care providers' needs following adverse events.
Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Fam Pract. 2013;30:56-63.
This survey of older adults who were taking more than five prescription medications daily found a strong association between poor physician–patient communication and an increased risk of patient-reported medication errors.
Mira JJ, Nebot C, Lorenzo S, et al. Qual Saf Health Care. 2010;19:e33.
Patients who reported experiencing an adverse drug event had shorter visits with physicians, were less likely to have been seen by their regular physician, and were less likely to have received specific information on potential medication side effects.