The PSNet Collection: All Content

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.

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Displaying 1 - 20 of 90 Results

Improving patient safety by shifting power from health professionals to patients.

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BMJ 2023(383):2219, 2278, 2319, 2331.

This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a new policy in the United Kingdom motivated by the death of a pediatric patient to sepsis and the systemic weaknesses contributing to the adverse outcome. The policy is intended to encourage patients and caregivers to request a second opinion if a patient’s health condition is deteriorating and they feel their concerns are not being taken seriously by the healthcare team. The articles discuss the importance effective communication between clinicians, caregivers, and patients, mitigating adverse impacts of hierarchies, and the role of patient and caregiver engagement in the design of safe healthcare systems.

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

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Wu AW, Papieva I, Sheridan S, et al. J Patient Saf Risk Manag. 2023;28:147-152.

True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

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Mauskar S, Ngo T, Haskell H, et al. J Hosp Med. 2023;18:777-786.

Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.

Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.

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Kieren MQ, Kelly MM, Garcia MA, et al. Acad Pediatr. 2023;Epub Jun 9.

Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.

Human centered design workshops as a meta-solution to diagnostic disparities.

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Wiegand AA, Dukhanin V, Sheikh T, et al. Diagnosis (Berl). 2022;9:458-467.

Previous research has identified gender and racial disparities in the burden of diagnostic errors. In this study, researchers conducted a series of human-centered design workshops with a diverse set of stakeholders who generated a set of design challenges, principles, and solutions for addressing diagnostic disparities, improving healthcare quality, and promoting equity and inclusion of marginalized patients. Participants also identified two prototypes for the solutions – a visit preparation guide to teach patients how to advocate for themselves and a tool for identifying patients who may be at increased risk for experiencing a diagnostic error.

Family safety reporting in hospitalized children with medical complexity.

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Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.

Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

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Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.

Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.

Poor physician-patient communication and medical error.

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Lazris A, Roth AR, Haskell H, et al. Am Fam Physician. 2021;103(12):757-759.

Communication failures are primary threat to safe care. This commentary shares insights on communication problems that contributed to unsafe medication prescribing from both a clinicians and a patient/family perspective.

Making Healthcare Safe: The Story of the Patient Safety Movement.

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Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 9783030711252.

The publication of “Error in Medicine” by Dr. Lucian Leape marked a pivotal step in the launch of the modern patient safety movement. In this publication, Dr. Leape shares insights stemming from his notable career in safety to outline milestones in the current effort to reduce patient harm due to medical mistakes.

Identifying barriers to and opportunities for telehealth implementation amidst the COVID-19 pandemic by using a human factors approach: a leap into the future of health care delivery?

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Zhang T, Mosier J, Subbian V. JMIR Hum Factors. 2021;8:e24860.

The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.

Health care provider factors associated with patient-reported adverse events and harm.

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Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.

This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.

Moving Measurement into Action: Global Principles for Measuring Patient Safety.

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IHI Lucian Leape Institute. Boston, MA: Institute for Healthcare Improvement, Salzburg Global Seminar; December 2019.

… use of the measures to generate improvement. … IHI Lucian Leape Institute. Boston, MA: Institute for Healthcare … Salzburg Global Seminar; December 2019. … IHI Lucian Leape Institute. Moving Measurement into Action: Global …

Unleash the power of patients to make care safer around the world: an essay by Helen Haskell.

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Haskell H. BMJ. 2019;366:l5565.

Patient safety is a global concern across the economic spectrum. This commentary summarizes activities associated with the first World Patient Safety Day and emphasizes how patient engagement is key to generating lasting improvements around the world to enhance patient safety.

Abandon the term "second victim."

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Clarkson MD, Haskell H, Hemmelgarn C, et al. BMJ. 2019;364:l1233.

The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

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Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

Patient Safety.

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Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety.

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Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.

Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.

Transforming concepts in patient safety: a progress report.

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Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.

Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

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Berger ZD, Brito JP, Ospina NS, et al. BMJ. 2017;359:j4218.

Engaging patients in their care is gaining recognition as a strategy to improve diagnosis. This commentary explores the role of shared decision making in building patient and clinician relationships that enable patient-centered diagnosis.

Americans' Experiences With Medical Errors and Views on Patient Safety.

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Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017.

… IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017. … NORC at the University of Chicago; IHI/NPSF Lucian Leape Institute; Institute for Healthcare Improvement; IHI; …

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