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.
Starmer AJ, Michael MM, Spector ND, et al. Jt Comm J Qual Patient Saf. 2023;49:384-393.
Multiple handoffs during perioperative care present opportunities for error. This article outlines a conceptual framework to support the development, implementation, and evaluation of patient-centered handoffs during perioperative care. The authors describe a multi-component handoff improvement bundle including mnemonics and checklists (such as I-PASS), technology solutions to reinforce verbal handoffs, interprofessional handoff training and assessment, and leadership support to promote safety culture.
Myers JS, Lane-Fall MB, Perfetti AR, et al. BMJ Qual Saf. 2020;29:645-654.
This study used a mixed-methods approach to characterize the impact of two academic fellowships in Quality Improvement Patient Safety (QIPS) to both graduates and their respective institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors also generally thought the fellowships were important and the resulting research had departmental, institutional and even national importance.
Lane-Fall MB, Davis JJ, Clapp JT, et al. Acad Med. 2018;93:904-910.
This analysis of specialty-specific milestones for graduate medical education found that about 40% mentioned patient safety or quality improvement. Emphasis on patient safety and quality improvement skills varied by specialty. The authors conclude that patient safety concepts are addressed in graduate medical education competencies.
Mardis M, Davis JJ, Benningfield B, et al. Am J Med Qual. 2017;32:34-42.
This systematic review examined the effect of handoff improvement interventions on patient outcomes. Studies were so heterogenous that authors could not reliably synthesize results, and they recommend more rigorous prospective controlled studies with pre-specified patient outcomes. A previous WebM&M commentary discusses strategies to enhance handoffs.
Mardis T, Mardis M, Davis JJ, et al. J Nurs Care Qual. 2016;31:54-60.
Incomplete handoffs and poor communication regarding key clinical information may lead to adverse events. According to this systematic review, current research on bedside nursing handoffs suggests this method (conducting handoffs at the patient's bedside, instead of in a conference room or nurses' station) can improve patient and staff satisfaction, but evidence regarding its effect on patient safety is largely lacking.