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.
Zwaan L, Smith KM, Giardina TD, et al. Patient Educ Couns. 2023;110:107650.
Improving diagnosis and diagnostic error-related harm is a major focus within patient safety. Building on previous research, patients and patient advocates participated in a systematic prioritization exercise and prioritized ten diagnostic error reduction research priorities. Prioritized questions focused on improving care integration/coordination, communication between clinicians and patients/caregivers, improving patient reporting systems, and improved understanding of implicit bias, and underlying factors increasing risk for diagnostic errors among vulnerable patient groups. The authors note that these priorities differed more than those identified previously by diagnostic safety experts and stakeholders.
Fisher KA, Smith KM, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2020;46:261-269.
This article evaluates the implementation of the We Want to Know program, which encourages hospitalized patients to speak up about breakdowns in care. Over a three-year period at one large, community hospital, the program interviewed over 4,600 patients and identified 822 (17.6%) who experienced a breakdown in care. Of those, 66.5% identified harm associated with the incident and 61.9% had spoken to someone at the hospital about it. Stakeholders (e.g., nurses, nurse managers, physicians, hospital administrators and leadership) found the program reports provided timely, actionable information and allowed for real-time responses and resolutions. Concerns cited by stakeholders included overlap with exiting patient safety reporting efforts, high level of effort and resources required, ensuring adequate responses.
Hatlie MJ, Nahum A, Leonard R, et al. Jt Comm J Qual Patient Saf. 2020;46:158-166.
Effectively engaging patients and family members is a necessary prerequisite to providing effective patient- and family-centered care. This article describes lessons learned during the six years after a large regional health care system in the U.S. established a systemwide infrastructure of patient and family advisory councils (PFACs) to help improve the quality, safety, and experience of care it provides. Successful elements are described, and the authors conclude that an openness to continuous improvement and adaptation was particularly important.
Fisher K, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Lambert BL, Centomani NM, Smith KM, et al. Health Serv Res. 2016;51:2491-2515.
Research has demonstrated that disclosing errors to patients results in fewer malpractice claims, but such discussions do not always take place. This observational study described the effect of implementing the AHRQ Communication and Optimal Resolution (CANDOR) toolkit, an intervention bundle intended to support error disclosure, at a single health system. The investigators found that incident reports increased, suggesting that more safety problems were identified and reported. Also, the number of malpractice claims, along with their resultant costs, decreased significantly. Using an interrupted time series design, they established that these outcomes persisted more than 7 years after the program was introduced. The authors suggest that such programs can result in significant cost savings to health systems. A past PSNet perspective discussed error disclosure in health care.
Mazor KM, Smith KM, Fisher K, et al. Ann Intern Med. 2016;164:618-9.
Although patients have been increasingly encouraged to speak up about concerns as a way to improve safety, health care institutions often have no system in place to ensure such concerns are promptly addressed. This commentary explores the disconnect between intention and action and suggests steps to be taken so that health systems can achieve benefits of patient engagement initiatives.