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.
Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.
Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.
Paine LA, Holzmueller CG, Elliott R, et al. J Healthc Risk Manag. 2018;38:36-46.
Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership decisions can have on organizational failure. The authors outline results and lessons learned from implementing the tool.
Pronovost P, Sutcliffe K, Basu L, et al. Bull World Health Organ. 2017;95:478-480.
Mental models represent established mindsets that can either hinder or enhance safety. This commentary describes mental models about patient safety that may limit progress, such as acceptance of harm as an expected byproduct of medical care. The authors provide suggested changes to these mindsets, including focusing on developing effective patient safety measures and a systems approach to designing and implementing improvement initiatives.
Sutcliffe K, Paine LA, Pronovost P. BMJ Qual Saf. 2017;26:248-251.
Health care has recently adopted high reliability as a goal, but progress to reaching that standard has been challenging. This commentary suggests that organizations working toward achieving high reliability must establish and sustain a culture of safety throughout the health care system.
Goldenhar LM, Brady PW, Sutcliffe K, et al. BMJ Qual Saf. 2013;22:899-906.
Seeking to improve situational awareness at the unit and organizational level, a tertiary care children's hospital implemented a huddle system to boost recognition of safety threats. This study describes how daily huddles took place at the unit level (the "micro level"), at the managerial level (the "meso level"), and at the leadership level (the "macro level"). The goals were to debrief safety events, identify high-risk patients and situations, and marshal organizational resources to address high-priority safety issues. The authors used qualitative methods to explain how this approach—which is grounded in the principles of high-reliability organizations—can lead to improvement in safety culture.
Vogus TJ, Sutcliffe K. Med Care. 2007;45:997-1002.
Case studies of high-reliability organizations reinforce the importance of maintaining an organizational commitment and a culture of safety. This study discovered that extensive use of care pathways increased the positive effects of safety organizing. Investigators surveyed nurses and nurse managers and linked their responses to reported medication errors on a given unit. While limitations exist with error reporting data, the authors conclude that organizations should avoid focusing on technical and organizational factors in isolation, as benefit occurs from coupling strategies.
The Agency for Healthcare Research and Quality (AHRQ) recommends that hospitals monitor the culture of safety to assess their specific needs for improvement. This study reports on how responses to a nursing survey administered at 13 Catholic health system hospitals were used to develop an instrument that measures safety culture. Higher scores on the resulting instrument, dubbed the Safety Organizing Scale (SOS), were associated with fewer reported medication errors and falls. A prior study evaluated the quality of safety culture measurement instruments and found that most had not been well validated.
Hoff TJ, Sutcliffe K. Jt Comm J Qual Patient Saf. 2006;32:5-15.
This commentary argues for the inclusion of diverse research methods, particularly qualitative ones, to improve and advance existing knowledge about patient safety. The authors provide a background discussion on the complexity of studying medical errors and the health care system itself in order to devise effective strategies for improvement. In this context, they offer a number of case examples to illustrate these challenges with greater discussion of the pros and cons to each methodological approach (a comprehensive table is included). Finally, a series of action steps are given for organizations to implement qualitative methods into their patient safety research agendas.
Engel KG, Rosenthal M, Sutcliffe K. Acad Med. 2006;81:86-93.
The authors interviewed residents and found that their ability to cope with adverse incidents relied on opportunities to learn from the experience and discuss the incident with colleagues and supervisors.
Rosenthal M, Cornett PL, Sutcliffe K, et al. J Gen Intern Med. 2005;20:404-9.
This qualitative study assessed how residents report or acknowledge the occurrence of medical errors. Investigators interviewed 26 residents to discuss 73 specific cases involving error. Results suggested that less than half of the errors were formally noted in the medical record, while only one-third received discussion but also were not documented. The authors conclude that health care providers represent a critical information source to better understand the systems that lead to errors. Both education about and discussion of medical errors should produce greater insight through increased acknowledgment of errors when they occur.
Sutcliffe K, Lewton E, Rosenthal M. Acad Med. 2004;79:186-194.
In order to better understand the impact of communication failures, this qualitative study analyzed interview findings from residents at a single teaching hospital. Study participants identified 70 "mishaps" in which communication and patient management factors contributed the most to the associated events. Several anecdotes illustrate the role communication failures played in these mishaps and how common these situations are in daily practice. The authors conclude that barriers to effective communication are both individual and systemic and that there is a need for both educational and organizational interventions.