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.
Ryan SL, Logan M, Liu X, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 31.
I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;10:1844-1855.e3.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels.
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.
Myers LC, Blumenthal K, Phadke NA, et al. Jt Comm J Qual Patient Saf. 2021;47:54-59.
Learning from adverse events is a core component of patient safety improvement. These authors developed guidance for the use of peer review protected information (such as voluntary event reports and root causes analyses) in safety research. The guidance aims to ensure that data are handled safely and appropriately while supporting scientific discovery.
This article describes an innovative expert consensus process to generate a contemporary list of chart-review based triggers and adverse event measures for assessing the incidence of inpatient and outpatient adverse events. A panel of 71 experts from nine institutions identified 218 triggers and measures with high or very high clinical importance deemed suitable for chart review and 198 were found suitable for electronic surveillance; 192 items were suitable for both.
This case-control study using medical malpractice claims identified patient-, provider-, and claim-related factors in claims directly involving physician trainees in the events. The majority of claims were procedure-related and the most common diagnosis in claims cases was puncture or laceration during surgery. Inadequate supervision was a common contributing factor.
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.
This retrospective cohort study based on medical malpractice claims from 2007-2016 explored the characteristics of paid claims in which physician assistants and advanced practice nurses are defendants.
This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Gartland RM, Alves K, Brasil NC, et al. Am J Surg. 2019;218:181-191.
This systematic review of the safety of overlapping surgery included 14 studies and did not find differences in 30-day mortality or overall morbidity in overlapping versus nonoverlapping surgery across a range of procedures. Researchers noted a small increase in length of procedure for overlapping surgeries. They conclude that overlapping surgery does not lead to higher risk for morbidity and mortality, despite the controversy associated with this practice.
Lagoo J, Berry WR, Miller K, et al. Ann Surg. 2019;270:84-90.
Physicians who receive more patient complaints about communication and behavior are more likely to face malpractice claims. This study examined whether results from surgeons' 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were associated with risk of malpractice claims. Surgeons with worse performance for attentiveness, informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons in the highest 10% for the negative behaviors of snapping at or talking down to others also were more likely to have malpractice claims. These results echo prior studies of physician behavior and malpractice risk. The authors suggest that addressing negative behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety surveillance.
Blanchfield BB, Acharya B, Mort E. Jt Comm J Qual Patient Saf. 2018;44:212-218.
Serious reportable events represent preventable safety hazards. Medical centers are required to investigate these events and report them to various regulatory agencies and, depending on state and local requirements, report them publicly. This case study describes the costs associated with reporting all serious reportable events at a single academic medical center during one fiscal year. The administrative costs to the medical center to investigate and prepare reports were about $8000 per event. Approximately 17% of the costs were attributed to the requirement for public reporting. The authors contend that the costs of performing public reporting of serious adverse events should be weighed against the benefits. A past WebM&M commentary discussed unintended consequences of public reporting and interventions to prevent them.
Shahian DM, Liu X, Rossi LP, et al. Health Serv Res. 2018;53:608-631.
Measuring safety culture is viewed as a best practice and is endorsed by the Leapfrog Group and the Agency for Healthcare Research and Quality (AHRQ). However, studies have not consistently demonstrated a direct relationship between safety culture and improved patient outcomes. In this observational cohort study, researchers analyzed data from 19,357 discharges for acute myocardial infarction (AMI) across 171 hospitals and associated data from AHRQ Hospital Survey on Patient Safety Culture surveys between 2008 and 2013. They found no association between 30-day AMI mortality and safety culture scores. A recent PSNet interview with Mary Dixon-Woods discussed the evolving concept of safety culture.
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266:582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Han K, Bohnen JD, Peponis T, et al. J Am Coll Surg. 2017;224:1048-1056.
Health care providers who experience psychological harm associated with adverse events are often referred to as second victims. This survey of surgeons found that the majority who could recall an intraoperative adverse event experienced negative emotions, and only a minority accessed formal support systems. This work emphasizes the need to build systems to provide support for second victims.
Shahian DM, McEachern K, Rossi L, et al. BMJ Qual Saf. 2017;26:760-770.
Handoffs among providers remain suboptimal despite the development of effective strategies to improve them. This quality improvement report described the implementation of I-PASS, an evidence-based handoff strategy that has shown to reduce adverse events, at an academic medical center. Investigators utilized a comprehensive implementation strategy that included leadership support, training of all staff, integrating electronic health record templates to facilitate performance of I-PASS, and engaging frontline staff. This multi-faceted approach is similar to prior work implementing patient safety strategies. To evaluate the intervention, the researchers conducted surveys of clinicians and observed handoffs to determine if I-PASS was actually in use. They found that I-PASS was more consistently used on medical and pediatric services than on surgical services, where it was felt to be less applicable to stable postsurgical patients. The prevalence of asynchronous handoffs posed a barrier to consistent implementation. This report demonstrates the complexity of implementing and evaluating an evidence-based safety intervention and underscores the need for frontline staff involvement in improving safety.