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.
Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.
Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
Seys D, De Decker E, Waelkens H, et al. J Patient Saf. 2022;18:717-721.
Burnout and stress among healthcare workers can adversely impact patient safety. Using data from two cross-sectional surveys, this study found the COVID-19 pandemic had a larger impact on the mental health and well-being of healthcare workers compared to involvement in a patient safety incident. Negative psychological symptoms such as anxiety, sleep deprivation, and wanting to leave the profession were all significantly higher in COVID-19-related groups.
Clinicians may experience distress after being involved in adverse events. This study of 4369 Dutch providers examined the prevalence and duration of clinicians' symptoms associated with involvement in an adverse event as well as the relationship between the degree of harm and symptom duration. As expected, clinicians reported symptoms such as hypervigilance, self-doubt, and discomfort following adverse events. These symptoms were more severe and long lasting for events with more serious harm to patients, compared to events with less severe harm. The authors call for organizations to provide support for clinicians involved in adverse events. A previous PSNet perspective discussed efforts to ameliorate the impact of errors on providers.
This synthesis of 19 qualitative studies of the second victim phenomenon, or the effects of an adverse outcome or error on clinicians, establishes a framework to characterize second victim experiences. The authors recommend including second victim perspectives into root cause analyses in order to improve safety culture.
Wu AW, Shapiro J, Harrison R, et al. J Patient Saf. 2020;16:65-72.
Word choice can impact buy-in for programs and integrating concepts across an organization. This review examines the term "second victim" as a label for health professionals involved in adverse events. The authors explore both constructive and negative reactions to the term and suggest that context and culture affect the appropriateness of its use.
Aiken LH, Sloane DM, Griffiths P, et al. BMJ Qual Saf. 2017;26:559-568.
Researchers analyzed patient discharge data and hospital characteristics, as well as patient and nurse survey data, across adult acute care hospitals in six European countries. After adjusting for hospital and patient variables, they found that hospitals in which nursing care was provided to a greater degree by skilled nurses had lower odds of mortality. The authors argue against replacing professional nurses with nursing assistants and suggest that doing so may compromise patient safety by increasing preventable deaths.
Van Gerven E, Elst TV, Vandenbroeck S, et al. Med Care. 2016;54:937-943.
Clinicians who are involved in an adverse event often experience significant emotional consequences, leading to the term "second victim." This survey of physicians and nurses in Belgium examined the relationship between involvement in an error in the past 6 months and clinicians' emotional state, risk of engaging in high-risk behaviors, and work–life balance. Involvement in an error was strongly correlated with burnout, potentially harmful medication use, and plans to leave the health care field. The cross-sectional nature of the study makes it difficult to discern causality, and other studies show that burnout increases the risk of committing an error. Nevertheless, this study adds to a growing body of literature demonstrating that errors have long-lasting harmful effects for clinicians. A qualitative study explored how clinicians recover from being involved in errors, and a WebM&M commentary describes ways that organizations can help clinicians in the recovery process.
Aiken LH, Sloane DM, Bruyneel L, et al. Lancet. 2014;383:1824-30.
This retrospective cohort study across nine European countries revealed that higher patient–nurse staffing ratios increased the likelihood of inpatient mortality. A larger proportion of nurses with bachelor's degrees decreased this risk, consistent with previous research that found a relationship between nurse education levels and patient outcomes. This finding emphasizes the importance of maintaining an adequately staffed and trained nursing workforce to support safety in hospitals.
Ausserhofer D, Zander B, Busse R, et al. BMJ Qual Saf. 2014;23:126-35.
Nurses are frequently forced to prioritize tasks during busy shifts, leading to some nursing care being left undone. In this multinational European study, nurses most frequently omitted time-intensive but critical practices such as talking with, educating, and providing comfort for patients.
Sarrechia M, Van Gerven E, Hermans L, et al. J Adv Nurs. 2013;69:278-85.
A considerable body of literature documents widespread variations in outcomes for patients hospitalized at different hospitals for similar conditions. Care pathways are intended to improve outcomes by standardizing use of evidence-based practices, and a surgical pathway was recently shown to markedly reduce both complications and postoperative mortality. However, this survey of obstetric care pathways for normal deliveries at Belgian hospitals found that the 17 pathways analyzed varied widely and did not consistently apply evidence-based practices to prevent postpartum complications. A devastating series of preventable complications during delivery, which led to the death of an infant, is discussed in this classic commentary, and lessons learned from the case have been incorporated into a video widely used for teaching purposes.
Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.
Seminal studies in the United States have shown strong associations between nurses' working conditions and patient safety, with high patient-to-nurse ratios and greater patient turnover being linked to increased mortality. This multinational survey of nurses and patients found that improved nurse work environments and reduced patient-to-nurse ratios were linked to better perceptions of quality and patient satisfaction. Moderately strong correlations were found between patient satisfaction and nursing reports of care quality, although there were wide variations in both measures across different countries. This study lends additional support to the view that improving the work environment for nurses can strengthen patient safety.