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.
Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;31:716-724.
… to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were … early warning system implemented to reduce adverse events: a qualitative study. BMJ Qual Saf. Epub 2022 Apr 15. …
Maatman TC, Prigmore H, Williams JS, et al. BMJ Qual Saf. 2019;28:934-938.
… safety … BMJ Qual Saf … This educational intervention used a comic book format to convey patient safety concepts to … to the pre-test, suggesting this modality has promise as a patient safety education tool. …
Fletcher KE, Singh S, Schapira MM, et al. Am J Med. 2016;129:341-7.e21.
This prospective cohort study across three sites with an internal medicine residency program found no relationship between resident discontinuity and adverse events. Safe handoffs have become even more essential in the era of resident duty hour restrictions.
… outcomes. However, this analysis of medical admissions to a teaching hospital found indications of an opposite association. Analyzing admissions over a 6-year period, investigators found that a higher total patient census and a greater number of daily …
Lamba R, Linn K, Fletcher KE. BMJ Qual Saf. 2014;23:667-9.
Although this direct observation study found that medical team rounds usually include conversation about patient safety concerns, appropriate mitigating action was discussed for only 50% of issues. The authors highlight how rounds offer an opportunity to detect potential risks and educate teams about patient safety in real time.
… to overcome. Studying important patient outcomes (e.g., mortality) is difficult, because of the (fortunately) … right will hopefully also help us get the answers right. … KathlynE. Fletcher, MD, MA … Associate Professor of MedicineClement J. …
This article discusses evidence surrounding the impact of resident duty hour limits on safety in health care.
Christopher P. Landrigan, MD, MPH, of Brigham and Women's Hospital has performed key studies on how sleep deprivation affects clinicians and strategies to mitigate such fatigue to improve patient safety, including seminal articles published in the New England Journal of Medicine in 2004 and 2010.
Antiel RM, Reed DA, Van Arendonk K, et al. JAMA Surg. 2013;148:448-55.
Recent research has examined residents' perceptions about the impact of duty hour restrictions. In this survey, surgical interns reported decreased patient care coordination, continuity of care, and time spent in the operating room, with no significant improvements in quality of life or reduced risk of burnout.
Wittich CM, Reed DA, Drefahl MM, et al. Acad Med. 2011;86:737-41.
This study found that residents’ reflections on improvement opportunities were stable over their 3-year training period, lower for systems reflections than for personal ones, and associated with the preventability of adverse events.
Fletcher KE, Reed DA, Arora V. J Gen Intern Med. 2011;26:907-919.
This systematic review of the effect of physician duty hour regulations found that the regulations were associated with improved resident well-being, but had mixed effects on resident educational outcomes and clinical outcomes.
Szostek JH, Wieland ML, Loertscher LL, et al. Am J Med. 2010;123:663-668.
… teach important principles of quality and safety through a variety of different frameworks . This study shares a structured systems audit framework that was applied to M&M … discussion of improvement opportunities and fostered a positive safety culture in exploring the events presented. …
Fletcher KE, Wiest FC, Halasyamani L, et al. J Gen Intern Med. 2008;23:623-8.
Resident work hours, fatigue, and discontinuity in care continue to be significant areas of concern in patient safety. This study surveyed inpatients from three different types of institutions to highlight the knowledge, concerns, and attitudes expressed by patients around these issues. Investigators were surprised to learn that the majority of patients were in fact not concerned about either fatigue or discontinuity despite media attention given to these topics. However, trust in physicians and satisfaction were related to the degree of concern about fatigue and discontinuity. Such perceptions among patients may be important in guiding future efforts to ensure patient-centered care.
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-8.
… case study presents the events surrounding the death of a woman admitted to an academic medical center with … to poor communication and handoffs (the latter is a 2007 National Patient Safety Goal ). The authors also … allowing autonomy for growth. This article is the last of a special collection entitled "Quality Grand Rounds," a …