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.
Christopher D, Leininger WM, Beaty L, et al. Am J Med Qual. 2023;38:165-173.
Staff engagement in safety and quality improvement efforts fosters a culture of safety and can reduce medical errors. This survey of 52 obstetrics and gynecology departments at academic medical centers found that few departments provided faculty with protected time or financial support for quality improvement activities, and only 5% of departments included a patient representative on the quality committee.
This commentary co-written by a medical student and a faculty member explores the presence and impact of implicit bias on the clinician team and patients. The piece introduces a four-step framework through which to examine the origins of bias, how its described, its care impact and how to reduce its effect.
The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.
Armstrong BA, Dutescu IA, Tung A, et al. Br J Surg. 2023;110:645-654.
Cognitive biases are a known source of misdiagnosis and post-operative complications. This review sought to identify the impact of cognitive biases on surgical performance and patient outcomes. Through thematic analysis of 39 studies, the authors identified 31 types of cognitive bias across six themes. Importantly, none of the included studies investigated the source of cognitive bias or mitigation strategies.
Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;30:838-845.
Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Hacker CE, Debono D, Travaglia J, et al. J Health Organ Manag. 2022;36:981-986.
Disinfection and cleaning of the hospital environment can promote a reduction in healthcare-associated infections. This commentary discussed the important, yet largely invisible, role of the hospital cleaning workforce. The authors also describe additional benefits provided by cleaners, such as reducing patient isolation and alerting clinical staff to patient changes.
Montgomery A, Lainidi O, Johnson J, et al. Health Care Manage Rev. 2023;48:52-60.
When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.
Yesmin T, Carter MW, Gladman AS. BMC Health Serv Res. 2022;22:278.
… study explored whether the use of “internet of things” (i.e., network of physical objects – “things” – that are … falls and improving hand-hygiene compliance . … Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare …
Chaudhry NT, Franklin BD, Mohammed S, et al. Pharmacy (Basel). 2021;9:198.
Data that is collected for clinical care and then reused to improve quality of patient care is referred to as secondary use of data (SUD). This review identified enablers and barriers to successful use of SUD to improve medication safety. The authors developed an integrated framework to describe the processes, mechanisms, and barriers for SUD.
Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8:e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.
Klatt TE, Sachs JF, Huang C-C, et al. Jt Comm J Qual Patient Saf. 2021;47:759-767.
This article describes the implementation of a peer support program for “second victims” in a US healthcare system. Following training, peer supporters assisted at-risk colleagues, raised awareness of second victim syndrome, and recruited others for training. The effectiveness of the training was assessed using the Second Victim Experience Support Tool. The most common event supported was inability to stop the progress of a medical condition, including COVID-19.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47:591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
Neves AL, Freise L, Laranjo L, et al. BMJ Qual Saf. 2020;29:1019-1032.
… health records (EHR) on measures of quality of care (i.e., patient-centeredness, effectiveness, efficiency, … EHRs with patients. … Neves AL, Freise L, Laranjo L, Carter AW, Darzi A, Mayer E. Impact of providing patients access to electronic health …
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Brunsberg KA, Landrigan CP, Garcia BM, et al. Acad Med. 2019;94:1150-1156.
Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.
Aaronson E, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019;39:19-29.
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.