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.
Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.
Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.
Ellis LA, Falkland E, Hibbert P, et al. Front Public Health. 2023;11:1217542.
Safety culture is recognized as an essential component of reducing or preventing errors and improving overall patient safety. This commentary calls for greater consistency in defining and measuring safety culture across settings. The authors describe challenges faced by patient safety professionals and researchers, and offer recommendations on overcoming them.
A strong safety culture encourages error reporting and supports a blame-free environment, and is frequently measured to develop appropriate interventions. This review identified nearly 900 studies that assessed hospital safety culture with response rates from 4% to 100%. The authors identify several factors that influence response rate: remote distribution (i.e., electronic or sent via mail), timing (e.g., beginning/end of resident rotations, COVID-19), and length of survey.
Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;52:1821-1825.
The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.
Ellis LA, Tran Y, Pomare C, et al. BMC Health Serv Res. 2021;21:1256.
… . The researchers identified that hospital “pace” plays a central role in understanding that relationship, and a … improve staff well-being and safety attitudes. … Ellis LA, Tran Y, Pomare C, et al. "Time is of the essence": relationship …
Safety culture has been studied in healthcare settings using a variety of methods. This systematic review identified 694 studies of safety culture in hospitals. Most used quantitative surveys, and only 31 used qualitative or mixed methods. Eleven themes were identified, with leadership being the most common; none of the methods or tools appeared to measure all 11 themes. The authors recommend that future research include both qualitative and quantitative methods.
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. BMC Med. 2020;18:340.
Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.
Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32:184-189.
Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.
In learning organizations, leadership behavior creates a supportive learning environment where concrete processes are in place to facilitate learning and encourage creativity among employees. Published in a series of quality improvement articles, this commentary suggests that a commitment to systems thinking and innovation is needed to achieve progress. Elements of a changed approach include a reduced focus on rules and policies and an enhanced effort to consider system interactions.
Churruca K, Ellis LA, Braithwaite J. BMC Health Serv Res. 2018;18:201.
Unit-level dysfunction creates observable violations that, once normalized, can result in organizational failure. This article explains how applying the broken windows theory in health care can enable understanding of workarounds that may escalate from helpful adjustments in practice to a manifestation of conditions that contribute to patient harm.
Mannion R, Braithwaite J. Int J Health Policy Manag. 2017;6.
Patient safety has been a persistent goal in health care for nearly two decades, but reductions in preventable patient harm remain challenging to sustain. This commentary explores limitations in current system-focused approaches to improvements and advocates for deeper exploration and adoption of strategies that recognize the complexity of the health care environment.
Hibbert PD, Molloy CJ, Hooper TD, et al. Int J Qual Health Care. 2016;28:640-649.
The Institute for Healthcare Improvement's Global Trigger Tool is widely used to identify adverse events. This systematic review found variation in how the tool is implemented, with differing rates of adverse events detected. The authors suggest modifying the trigger tool to capture errors of omission and to assess the preventability of events identified.
Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015.
… how things usually go right. The authors suggest that a combination of the approaches is necessary to achieve … systems to enhance safety. … Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care … Net; 2015. … Braithwaite J.safety IIsafety I … E … RL … Jeffrey … Hollnagel … Wears … Braithwaite … E Hollnagel … RL …
Mumford V, Greenfield D, Hogden A, et al. BMJ Open. 2014;4:e005284.
… examine whether hand hygiene compliance rates may serve as a reliable indicator of hospital accreditation outcomes. The … scores, but their results did not support this hypothesis. A previous study from Canada found that increasing overall … of key hospital-acquired infections , possibly due to a ceiling effect. A recent AHRQ WebM&M perspective reviewed …
Lawton R, Taylor N, Clay-Williams R, et al. BMJ Qual Saf. 2014;23:880-3.
This commentary advocates for organizations to adopt an approach that focuses on top performers and team achievements to motivate improvement. Highlighting how positive deviance has demonstrated an encouraging effect on hand hygiene compliance, the authors suggest that this method could address behaviors that hinder adoption of safety practices.
Hughes C, Pain C, Braithwaite J, et al. BMJ Qual Saf. 2014;23:714-7.
… This commentary describes the design and implementation of a patient charting initiative based on principles from a surf lifesaving program in Australia. The intervention … vital signs to create visual triggers for timely launch of a medical emergency team . …