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.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.
Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.
Roberts SE, Rosen CB, Keele LJ, et al. JAMA Surg. 2022;157:1097-1104.
Missed steps in the diagnostic process, such as timely referral for surgical consultation, can lead to missed or delayed diagnoses. This large, retrospective cohort study using Medicare data identified disparities between Black and White patients in receipt of consults for emergency surgery. Findings show that Black patients had lower odds of receiving a surgical consultation after being admitted from the emergency department; these disparities remained after adjusting for medical comorbidities, socioeconomic factors, and individual hospital-level effects.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.
Viscardi MK, French R, Brom H, et al. Policy Polit Nurs Pract. 2022;23:5-14.
Health care work environments can influence safety culture and teamwork. This study used multiyear survey data from registered nurses in 503 hospitals across four states to explore the association between nurse work environment and healthcare quality, patient safety, and patient outcomes. Findings indicate that nurse work environment (such as nurse participation in hospital affairs, nurse manager capability, leadership support, and nurse-physician relationships) is an important factor to improving the experiences of patients and nurses, especially those in hospitals caring for economically disadvantaged patients.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
… minimum staffing ratios can improve patient outcomes. … McHugh MD, Aiken LH, Sloane DM, et al. Effects of nurse-to-patient ratio … and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. The Lancet. …
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8:639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.
Lake ET, Roberts KE, Agosto PD, et al. J Patient Saf. 2021;17:e1546-e1552.
… . Researchers measured the hospital work environment using a validated scale, and they assessed safety using the AHRQ Survey on Patient Safety Culture . A culture of blame and fear of speaking up remained prevalent … prior studies, investigators found an association between a high-functioning work environment and positive safety …
Ofoma UR, Basnet S, Berger A, et al. J Am Coll Cardiol. 2018;71:402-411.
The weekend effect has been observed for many conditions. A patient who has an in-hospital cardiac arrest at night or during the weekend is less likely to be successfully resuscitated or survive hospitalization than a patient whose heart stops in the hospital on a weekday. In this large retrospective cohort study, researchers examined trends in in-hospital cardiac arrests over 15 years. Resuscitation and survival to hospital discharge improved nearly 75% overall. The weekend effect persisted, especially in survival to hospital discharge. An accompanying editorial hypothesizes that during nights and weekends fewer specialists are available and fatigue may impair providers' psychomotor skills. A previous PSNet interview highlighted techniques for achieving high reliability at all times of day.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Lake ET, de Cordova PB, Barton S, et al. Hosp Pediatr. 2017;7:378-384.
Missed nursing care is common and has been linked to adverse events. This survey found that more than half of pediatric intensive care unit nurses reported missing care during their prior shift. Higher patient loads and poor working environments were associated with more episodes of missed care, corroborating prior research.
Wolfe H, Zebuhr C, Topjian AA, et al. Crit Care Med. 2014;42:1688-95.
This single-center prospective study found that providing interdisciplinary post-event debriefs with quantitative feedback on chest compression depth, rate, and other indicators of high-quality cardiopulmonary resuscitation significantly improved cardiac arrest outcomes in a pediatric intensive care unit.
Carthon MB, Lasater KB, Sloane DM, et al. BMJ Qual Saf. 2015;24:255-263.
… subsequent readmissions are warranted. A recent AHRQ WebM&M perspective discusses the nursing workforce and patient safety. … Carthon JM, Lasater KB, Sloane DM, Kutney-Lee A. The quality of hospital work …