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.
Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;31:867-877.
Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.
Miller FA, Young SB, Dobrow M, et al. BMJ Qual Saf. 2020;30:331-335.
The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.
Shojania KG, Marang-van de Mheen PJ. BMJ Qual Saf. 2020;29.
This commentary discusses the two ‘gold standard’ research methods used to identify adverse events– retrospective record review and prospective surveillance using triggers. The authors note that these approaches have served to demonstrate the scope of the patient safety problem and to engage clinicians, managers, researchers and policy makers. However, looking forward, they advocate moving away from the imperfect gold standard of adverse event rates and embracing more specific measures of important safety problems.
Wong BM, Baum KD, Headrick LA, et al. Acad Med. 2020;95:59-68.
An international group of educational and health system leaders, educators, front-line clinicians, learners, and patients convened to create a list of actionable strategies that organizations can use to better integrate Quality Improvement Patient Safety (QIPS) education with clinical care. A framework and list of concrete examples describe how groups can get started.
Mondoux S, Shojania KG. J Eval Clin Pract. 2019;25:363-368.
Evidence-based medicine has generated some controversy in quality and safety circles. The commentary highlights weaknesses in the science of evidence-based medicine and suggest that a broader systems-based approach is needed to inform health system redesign and improvement work.
Trbovich PL, Shojania KG. BMJ Qual Saf. 2017;26:350-353.
Although root cause analysis is an established strategy to investigate incidents, some have questioned its effectiveness in health care. Drawing from a recent study, this editorial suggests that robust health care investment in human factors engineering and safety science is needed to help root cause analysis achieve its full potential as an improvement mechanism. A recent Annual Perspective discussed ongoing problems with the root cause analysis process and described opportunities to improve its application in health care.
Leis JA, Shojania KG. BMJ Qual Saf. 2017;26:572-577.
Although plan–do–study–act (PDSA) cycles were promoted as an in-depth rapid-cycle improvement mechanism, this process can fall short of advancing an organization's improvement work. Exploring shortcomings as reflected in the literature, this article relates insights drawn from a project review to discuss how to effectively use PDSA cycles in patient safety work.
Shojania KG, Dixon-Woods M. BMJ Qual Saf. 2017;26:423-428.
A recent article asserted that medical error is the third leading cause of death in the United States. This perspective questions the accuracy of this estimate. The authors note that this estimate was generated by simply combining medical error rates from prior studies, without adhering to guidelines for quantitative synthesis or accounting statistically for the uncertainty associated with the extrapolation of these studies. There are also inherent limitations in the original data, which used trigger tools to identify adverse events. The studies from which the error rates were calculated could not clearly determine whether the adverse events detected actually contributed to the patient's death. Patients who are critically ill tend to have more adverse events because they experience more medical interventions. However, their deaths may be due to the underlying illness rather than the medical care they received. The authors argue that an inaccurately high estimate for medical error–related mortality draws attention away from other crucial patient harms, such as pressure ulcers and medication safety, both of which rarely contribute to mortality but are of high priority to patients.
Kovacs-Litman A, Wong K, Shojania KG, et al. J Hosp Med. 2016;11:862-864.
This study compared covert hand hygiene observation by students to traditional overt hand hygiene audits. Investigators found much lower hand hygiene performance with covert observation, especially for nurses, suggesting that covert observation may be more accurate. These results demonstrate the challenge of achieving optimal hand hygiene compliance.
Gandhi TK, Berwick DM, Shojania KG. JAMA. 2016;315:1829-30.
This commentary discusses findings from the National Patient Safety Foundation report investigating the state of patient safety in the 15 years after To Err Is Human. Focusing on the recommendation that leadership establish and sustain a culture of safety, the authors describe how leaders can engage board members and organizational leadership in this work and highlight the need to provide leaders with education and practical tools.
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Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.
Amaral ACK-B, McDonald A, Coburn NG, et al. BMJ Qual Saf. 2015;24:764-8.
There is a consensus in the safety field that organizations must use multiple methods of detecting errors and adverse events, as individual approaches vary in their ability to identify different types of safety issues. Rapid response systems (RRSs) have been widely deployed to detect and stabilize deteriorating hospitalized patients, and this study investigated whether analysis of RRS activations could be used to identify preventable hazards. Systematic review of patients seen by the RRS revealed that almost 20% had experienced an adverse event, 80% of these were preventable, and most were not reported to the institution's incident reporting system. Hospitals should consider formal review of RRS activation as a trigger for identifying adverse events.
Wong BM, Dyal S, Etchells E, et al. BMJ Qual Saf. 2015;24:272-81.
This prospective error investigation study combined a trigger approach to identify possible adverse events with medical record review and structured interviews to determine underlying causes for adverse events. Investigators found that a myriad of factors contribute to adverse events, and multiple distinct interventions would be needed to prevent the detected events. The authors advocate for a framework to classify underlying causes together when they can be addressed by the same intervention.
Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.