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.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;79:2230-2243.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Adler-Milstein J, Sarkar U, Wachter RM. J Patient Saf Risk Manag. 2022;27:160-162.
Electronic health records (EHR) house and provide access to a plethora of data to inform care and management decisions. This commentary suggests that EHRs have yet to be fully embraced as a tool to proactively identify areas of risk that could lead to legal action.
Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;48:539-548.
… Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience … attainment, racial and/or ethnic minority). … Olazo K, Wang K, Sierra M, et al. Preferences and perceptions of medical …
Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;48:492-496.
… claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed … documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed. … Gupta K, Szymonifka J, Rivadeneira NA, et al. Factors associated …
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;48:395-402.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
… to identify facilitators and barriers to reducing burnout. A common facilitator was peer support , and barriers included shame and a punitive work environment. … Gupta K, Rivadeneira NA, Lisker S, et al. Multispecialty physician …
Patients and families represent an often untapped resource in identifying errors and adverse events. Using a mobile health tool, pediatric patients and families were encouraged to report safety events that occurred during the child’s hospital stay. These reports were compared with incident reports (IRs) submitted to the internal incident reporting system. Of the 51 potential IR observations, only one had been submitted to the IR system. Notably, differences in the number of reported events varied by race, ethnicity, insurance status, and other marginalized groups, highlighting a need to explicitly engage these populations.
Vela MB, Erondu AI, Smith NA, et al. Annu Rev Public Health. 2022;43:477-501.
Implicit biases among healthcare providers can contribute to poor decision-making and impede safe, effective care. This systematic review assessed the efficacy of interventions designed to reduce explicit and implicit biases among healthcare providers and students. The researchers found that many interventions can increase awareness of implicit biases among participants, but no intervention achieved sustained reduction of implicit biases. The authors propose a conceptual model illustrating interactions between structural determinants (e.g., social determinants of health, language concordance, biased learning environments) and provider implicit bias.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Centola D, Guilbeault D, Sarkar U, et al. Nature Commun. 2021;12:6585.
Race and gender bias in healthcare remains a public health problem. Study participants were assigned to a control (i.e., independent reflection) or intervention (i.e., “egalitarian” information exchange network) group and asked to provide diagnostic and treatment recommendations for standardized patients (a white man or a black woman). Participants in the intervention group were more likely to recommend appropriate care and showed no bias in final recommendations. The authors note that these findings indicate that clinician network interventions might be useful in healthcare settings to reduce disparities in patient treatment.
Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10:e001421.
Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.
Vulnerable populations are more likely to experience patient safety events. This editorial presents six recommendations for the patient safety field to support advances in health equity: (1) including health equity experts on interdisciplinary patient safety teams, (2) examining systems for bias, (3) considering the influence of social determinants of health on safety issues, (4) developing validated performance measures, (5) leveraging implementation science to scale-up and disseminate effective interventions, and (6) nurture moral incentives to improve equity in patient safety.
Sharma AE, Yang J, Del Rosario JB, et al. Jt Comm J Qual Patient Saf. 2021;47:5-14.
… settings are receiving increased attention as a focus for patient safety improvements . Using data from a multistate patient safety organization (PSO) database, … for ambulatory care? Analysis of incident reports from a patient safety organization. Jt Comm J Qual Patient Saf. …
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.
The use of collective intelligence platforms may have the potential to improve diagnostic accuracy in primary care, but little is known about the attitudes of primary care providers toward such platforms. This qualitative study found that primary care providers might be willing to use such platforms as long as they are easy to use, perceived as helpful and accurate, and that the collective opinions generated can be trusted.
Gupta K, Lisker S, Rivadeneira NA, et al. BMJ Qual Saf. 2019;28:564-573.
… were more likely to report burnout . Participants reported a wide variety of errors; treatment errors were the most … mitigate burnout among second victims are urgently needed. A previous PSNet interview discussed the second victim …
Khoong EC, Cherian R, Rivadeneira NA, et al. Health Aff (Millwood). 2018;37:1760-1769.
California's Medicaid pay-for-performance program requires safety-net health care systems to report and improve upon diverse ambulatory safety measures. Researchers found that participating safety-net hospitals struggled to report accurate data. Systems had more success improving metrics that placed patients at risk of life-threatening harm when compared to metrics that required longer term follow-up or patient engagement.