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.
Barnard C, Chung JW, Flaherty V, et al. Jt Comm J Qual Patient Saf. 2022;48:430-438.
Organizations such as The Joint Commission and the Leapfrog Group require participating healthcare organizations to evaluate their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five questions with comparable measurement properties of the original 17-question survey; however, the authors caution the shorter survey will yield less detail than the longer version.
Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47:604-607.
Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.
Bilimoria KY, Barnard C. JAMA. 2021;325:2151-2152.
The Hospital Star Rating system was implemented in 2016 to aid patients in identifying safe, high-quality hospitals. The system has evolved over time to address applicability concerns. This commentary highlights changes in the latest reiteration of the program and discusses challenges in its use.
Merkow RP, Shan Y, Gupta AR, et al. Jt Comm J Qual Patient Saf. 2020;46:558-564.
Postoperative complications can increase costs due to additional healthcare utilization such as further testing, reoperation, or additional clinical services. This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to estimate 30-day costs resulting from postoperative complications. Prolonged ventilation, unplanned intubation, and renal failure were associated with the highest cost per event, whereas urinary tract infection, superficial surgical site infection, and venous thromboembolism were associated with the lowest cost per event.
This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.
Yuce TK, Yang AD, Johnson JK, et al. JAMA Surg. 2020;155:934-940.
This study used the Safety Attitudes Questionnaire to explore whether participation in a comprehensive, multicomponent, statewide surgical quality collaborative is associated with changes in hospital safety culture. Survey results identified significant improvements in teamwork climate and safety climate, as well as improvements in physician-nurse collaboration, reporting of concerns, and reduction in communication breakdowns.
Zhang LM, Ellis RJ, Ma M, et al. JAMA. 2020;323:2093-2095.
In this survey of 6,264 US general surgery residents, 70% reported experiencing at least one bullying behavior during surgical training and 18% reported frequent bullying. The most common types of bullying behavior were repeated reminders of mistakes, being shouted at, withholding of important information, persistent criticism, and hostility. Women and racial/ethnic minorities reported more frequent bullying. Residents reporting frequent bullying had higher rates of burnout, suicidal thoughts, and thoughts of leaving surgical training.
Hewitt DB, Ellis RJ, Chung JW, et al. Ann Surg. 2021;274:396-402.
This cross-sectional survey of general surgery residents to assessed resident wellness and self-reported error and compared these results against National Surgical Quality Improvement Program (NSQIP) registry data to assess patient outcomes. Over a six-month period, 22.5% of residents self-reported a near-miss medical error and nearly 7% reported an error resulting in patient harm. Residents reporting harmful medical errors were more likely to report symptoms of burnout and poor psychiatric well-being, but researchers did not find any significant association between well-being and adverse postoperative patient outcomes reported in the NSQIP registry.
Hu Y-Y, Ellis RJ, Hewitt B, et al. New Engl J Med. 2019;381:1741-1752.
Physician burnout can negatively impact not only physician well-being, but patient safety as well. This national survey of general surgery residents found that about one-third of all respondents reported experiencing discrimination or abuse; 38.5% of residents reported weekly burnout systems and 4.5% reported suicidal thoughts within the past year. Residents reporting burnout or suicidal thoughts were more likely to have experienced discrimination, abuse or sexual harassment. Women reported more exposure to mistreatment, which may account for gender differences in rates of burnout and suicidal thoughts.
Ellis RJ, Schlick CJR, Feinglass J, et al. BMJ Qual Saf. 2020;29:103-112.
This retrospective study of cancer care safety examined the extent to which patients received recommended chemotherapy. A significant proportion of breast, lung, and colorectal cancer patients did not receive chemotherapy; patients who were black and those lacking health insurance or covered by Medicaid were at higher risk. There was marked variability in chemotherapy delivery by location and hospital. The authors conclude that failure to administer chemotherapy is a significant safety gap that should be addressed.
Odell DD, Quinn CM, Matulewicz RS, et al. J Am Coll Surg. 2019;229:175-183.
Establishing a strong culture of safety is an important priority in the health care setting. Prior research examining the association between improved safety culture and patient outcomes has produced mixed results. Using a modified version of the Safety Attitudes Questionnaire (SAQ), researchers surveyed hospital leaders and frontline providers across 49 hospitals in the Illinois Surgical Quality Improvement Collaborative. Consistent with prior research, they found that hospital administrators had more positive perceptions of safety than frontline health care providers. They also found a significant association between improved safety culture as measured by the SAQ and reduced risk of postoperative morbidity and death. A past PSNet perspective discussed the impact of safety culture on safety.
Prior studies have found that patients are often prescribed opioids inappropriately after undergoing surgery. This qualitative study reports on the implementation of a multifaceted effort to reduce opioid prescribing and standardize postoperative pain management at an academic hospital. The investigators identified several barriers to improving prescribing, including time and resource constraints and fear of harming patient satisfaction.
Blay E, Engelhardt KE, Hewitt B, et al. JAMA Surg. 2018;153:860-862.
This secondary analysis of a prior randomized trial of flexible versus mandated duty hours for trainee physicians examined reasons for staying past the end of a 24-hour call. Most trainees reported voluntarily staying longer, though a significant proportion reported that program, attending, or senior resident expectations to stay longer influenced them. Reports of coercion to remain were less common, and the authors urge programs to ensure that trainees are not being coerced to exceed duty hours.
Desai SV, Asch DA, Bellini LM, et al. New Engl J Med. 2018;378:1494-1508.
Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.
Blay E, Barnard C, Bilimoria KY. JAMA. 2018;319:495-496.
This commentary describes a case involving a patient with obstructive sleep apnea who received multiple sedating medications and subsequently had a cardiac arrest while undergoing MRI. The authors explore root causes and provide suggestions for improving the safety of care for patients with obstructive sleep apnea.
This case report describes an insulin dosing error during hospitalization. The investigation uncovered several root causes, including lack of a standardized medication double-check. The authors note that prompt error disclosure to the patient and family was performed, and the patient required additional monitoring but experienced no further harm.