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.
Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.
Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.
Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;182:720-728.
Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.
Ottosen MJ, Sedlock E, Aigbe AO, et al. J Patient Saf. 2021;17:e1145-e1151.
This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8:100496.
Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning.
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46:591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.
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.
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
This study held focus groups with breast cancer providers to better understand attitudes and experiences regarding communicating with patients about diagnostic errors. Researchers presented three hypothetical vignettes for discussion. Participants identified challenges related specifically to breast cancer as well as challenges stemming from team-based care. To improve communication about these errors, participants recommended educating patients, being honest and empathetic, and focus on the positive and the patient’s future.
Brown SD, Bruno MA, Shyu JY, et al. Radiology. 2019;293:30-35.
This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.
Moore JS, Mello MM, Bismark M. Bioethics. 2019;33:948-957.
Patient engagement is now acknowledged as a cornerstone of patient safety, but the perspectives of patients who have experienced adverse events remain understudied. This interview study of 92 patients who had experienced iatrogenic injury identified several insights about the aftermath of adverse events. As with prior studies, researchers found that patients expressed a desire to be heard. Participants had positive perceptions of patient safety research and expressed a desire that others learn from the adverse event they experienced. The authors suggest that institutional review boards permit investigators to approach patients who have experienced adverse events to participate in studies, rather than prohibit such studies due to fear of causing further psychological harm. They also recommend that researchers discuss these adverse events with patients through a reciprocal lens, expressing support and sympathy rather than maintaining an emotionally distant stance. A previous PSNet interview with the lead author discussed disclosure and apology in health care.
Studdert DM, Spittal MJ, Zhang Y, et al. N Engl J Med. 2019;380:1247-1255.
Malpractice claims can shed light on patient safety hazards. This observational study examined how paid malpractice claims affected physicians' practice. Investigators found that a small proportion of physicians, about 10%, had one or more paid malpractice claims, consistent with prior studies. Approximately 2% of physicians accounted for nearly 40% of paid claims. Physicians with paid claims were more likely to leave clinical practice and more likely to move to smaller practice settings. The authors raise the concern that physicians who move to smaller practice settings may lack the institutional and peer support to remediate their clinical skills and behavior. A PSNet perspective explored the risk of recurring medicolegal events among providers who have received multiple malpractice claims.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.