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.
Wahl K, Stenmarker M, Ros A. BMC Health Serv Res. 2022;22:1101.
Patient safety huddles generally use a Safety-I approach to learn from errors and increase team awareness about safety threats. This mixed-methods study found that patient safety huddles including a focus on learning from what works well (Safety-II) may be beneficial to healthcare organizations, particularly if they can purposely focus on learning from both negative and positive experiences.
Strid EN, Wåhlin C, Ros A, et al. BMC Health Serv Res. 2021;21.
Based on semi-structured interviews with healthcare workers in Sweden, the authors explored how individuals, team members and managers respond to critical incidents. Critical incidents are emotionally distressing for healthcare workers but teamwork and trust among teams can facilitate safe practices and help individuals overcome emotional distress. Respondents also highlighted the importance of organizational support for managing risks, individual closure, and providing support after an incident.
Holmqvist M, Thor J, Ros A, et al. BMC Health Serv Res. 2021;21:557.
Polypharmacy in older adults puts them at risk for adverse drug events. In interviews with primary care clinicians, researchers found that working conditions and working in partnership with colleagues, patients, and family influenced medication evaluation. They also identified two main areas of action: working with a plan and collaborative problem-solving.
Fröding E, Gäre BA, Westrin Å, et al. BMJ Open. 2021;11:e044068.
In Sweden, patient suicide following contact with a healthcare provider is regarded a potential case of patient harm and must be investigated and reported to the Swedish supervisory authority. This retrospective study analyzed reported cases across three timeframes and concluded the investigations were largely suited to fit the requirements of the supervisory authority rather than an opportunity for organizational learning to advance patient safety. A 2019 PSNet Spotlight Case highlights systems issues that contributed to a patient’s suicide following discharge from the Emergency Department.
Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf. 2016;25:e7.
The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.