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.
Edwards MT. Int J Qual Health Care. 2018;30:602-607.
Peer review processes are frequently touted as a means for improving health care quality and safety, but they often lack standardization and evidence-based approaches. This survey study suggests that adopting certain best practices might make peer review programs more effective.
Just culture is a movement to shift from blame for errors and instead focus on system issues in order to enhance event reporting and learning from failures. This study examined a survey about just culture in conjunction with Hospital Compare quality ratings and AHRQ's Hospital Survey on Patient Safety Culture. The vast majority of the 270 hospitals that responded to the survey reported adopting just culture. However, respondents reported no improvement in nonpunitive response to error, indicating that a culture of blame persists. The study also found no association between hospital quality ratings and just culture implementation. The author concludes that just culture is not sufficient to create a blame-free culture in hospitals. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Edwards MT. American Journal of Medical Quality. 2016;32.
Organizations are encouraged to learn from their failures, but evidence shows that changes after errors are not always implemented. This commentary presents a model to help organizations learn from system failures through focusing on improvements that align collaboration, accountability, culture, and process enhancement with elements of high reliability.
This study examined peer review programs from nearly 300 acute care hospitals and discovered that they uncover notable variations in objective performance measures. The authors advocate for a shift from traditional quality assurance methods to a nonpunitive process infused with quality improvement principles.