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.
Kesselheim JC, Shelburne JT, Bell SK, et al. Acad Pediatr. 2021;21:352-357.
… trainees at two large children’s hospitals on attitudes and behaviors in regard to speaking up about traditional safety threats and unprofessional behavior . While trainees more commonly … trainees' speaking up about unprofessional behavior and traditional patient safety threats. Acad Pediatr. Epub …
Finn KM, Halvorsen AJ, Chaudhry S, et al. J Gen Intern Med. 2020;35:3205-3209.
This article reports on results from a 2017 survey of internal medicine residency program directors’ support for flexible work hours introduced by the Accreditation Committee on Graduate Medical Education (ACGME) based on trial results. Although the majority of programs supported the ACGME work hour flexibility, only one quarter of programs introduced longer work hours.
… cases administered over an online platform. Attending and resident physicians had higher diagnostic accuracy scores … measure combining these two constructs. … Chatterjee S; Desai S; Manesh R; Junfeng S; Nundy S; Wright SM. … S … S … R … S … S … SM … Chatterjee … Desai … Manesh … Junfeng … Nundy … Wright … S Chatterjee … S …
Clark BW, Derakhshan A, Desai S. Med Clin North Am. 2018;102:453-464.
… of diagnostic errors , including cognitive biases and large-scale system weaknesses . The authors suggest … clinical knowledge, physical examination practice , and medical history-taking skills to improve diagnosis. …
Lehmann LS, Sulmasy LS, Desai S, et al. Ann Intern Med. 2018;168:506-508.
… glean messages from the offhand comments, behaviors, and attitudes of their superiors, a phenomenon known as the … curriculum often runs counter to a culture of safety and standards of equitable treatment. In this position … in physician training through promoting an expectation of professionalism as a core value, empowering learners to raise …
Mathews SC, Pronovost P, Biddison LD, et al. Am J Med Qual. 2018;33:413-419.
Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.
Dykes PC, Rozenblum R, Dalal A, et al. Crit Care Med. 2017;45.
Establishing a strong safety culture may lead to a reduction in adverse events. Many health care institutions are focused on improving multiple aspects of culture including teamwork, communication, and patient engagement to mitigate harm. In this prospective study, researchers sought to understand the impact of a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit. They included 1030 admissions in the baseline period and 1075 in the intervention period. The rate of adverse events decreased by almost 30%, from 59.0 per 1000 patient days in the baseline period to 41.9 per 1000 patient days during the intervention period. Patient and care partner satisfaction improved as well. A past PSNet perspective discussed the relationship between patient engagement and patient safety.
Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017;26:869-880.
Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.
Asch DA, Bilimoria KY, Desai S. N Engl J Med. 2017;376:1704-1706.
The effect of resident work hours on patient safety has been controversial. This perspective summarizes the debate on resident duty hours in the context of recent changes to standards that allow for more flexibility in shift length. The authors underscore the importance of randomized trials, which investigators had utilized to explore the impact of flexible duty hours and served to inform the new policy.
Martinez W, Lehmann LS, Hu Y-Y, et al. Jt Comm J Qual Patient Saf. 2017;43:5-15.
… Joint Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This survey … medical center identified multiple conferences, meetings, and processes in which adverse events or near misses were … whether these events were reviewed at a morbidity and mortality conference , educational conference, or …
Martinez W, Etchegaray J, Thomas EJ, et al. BMJ Qual Saf. 2015;24:671-80.
… validated two new surveys (Speaking Up Climate-Safety and Speaking Up Climate- Professionalism) for measuring aspects of safety culture that … likelihood of speaking up about patient safety concerns and unprofessional behavior . Both scales performed well on …
Martinez W, Hickson GB, Miller BM, et al. Acad Med. 2014;89:482-9.
Although physicians generally support disclosing adverse events, they often choose their words carefully when discussing errors with patients. Since few training programs include formal curricula in error disclosure, most residents and medical students learn these skills through direct observation of senior clinicians. This survey of trainees evaluated the effects of negative and positive role models on their attitudes and behaviors regarding error disclosure. Most trainees had observed a harmful medical error, and the majority reported exposure to positive role models. Poor role models were associated with negative trainee attitudes about disclosure and an increased likelihood of trying to evade responsibility for harmful errors. More than one-third of trainees reported nontransparent behavior in response to a harmful medical error they had made. Addressing the importance of role models in shaping clinicians' future behaviors will be important to advancing full disclosure efforts. An AHRQ WebM&M perspective by Dr. Albert Wu discusses the importance of disclosing adverse events.
Gallagher TH, Mello MM, Levinson W, et al. N Engl J Med. 2013;369:1752-7.
Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.
Block L, Wu AW, Feldman LS, et al. Postgrad Med J. 2013;89:495-500.
Signs of burnout and fatigue were most often associated with being on a rotation that included shifts longer than 24 hours, in this survey of intern physicians at three internal medicine residency programs. The survey was performed immediately prior to implementing the 2011 duty hour restrictions, limiting intern shifts to 16 hours.
Kaushal R, Goldmann DA, Keohane C, et al. Ambul Pediatr. 2007;7:383-9.
The incidence of adverse drug events (ADEs) among children has been well characterized in hospital inpatients, but less studied in the outpatient setting. Conducted at six pediatric outpatient practices, this AHRQ-funded prospective cohort study evaluated the frequency of medication errors via chart review, review of prescriptions, and patient surveys. The overall rate of preventable ADEs was similar to a prior outpatient study, but nearly three-quarters of events were attributable to errors in administering drugs by the parents. Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading the authors to conclude that communication between clinicians and parents around the issue of medication side effects must be improved.