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.
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. J Patient Exp. 2022;9:237437352211026.
Combining patient complaints and staff incident reports allows hospitals to better understand causes of patient harm. This children’s hospital designed a program to investigate serious experience events (SEE) modeled after their serious safety events (SSE) program. Through case studies, the authors describe how patient complaints were investigated to improve both patient experience and safety.
Foster C, Doud L, Palangyo T, et al. Pediatr Qual Saf. 2021;6:e434.
Healthcare worker safety has been linked to overall safety culture. A pediatric hospital adapted patient safety event reporting infrastructure and definitions to worker safety reporting. Implementation of the worker safety reporting system reduced time from injury to reporting, identified safety gaps, and improved worker satisfaction with the reporting process.
Destino LA, Dixit A, Pantaleoni JL, et al. Jt Comm J Qual Patient Saf. 2017;43:80-88.
Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.
Larson DB, Donnelly LF, Podberesky DJ, et al. Radiology. 2017;283:231-241.
Improving the culture of safety within health care is an essential component of preventing errors. This commentary discusses the culture of radiology in the context of recent progress in understanding and reducing diagnostic error. The authors suggest that peer-oriented feedback and assessment would drive progress in improving safety in radiology.