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.
Black GB, Lyratzopoulos G, Vincent CA, et al. BMJ. 2023;380:e071225.
Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.
Averill P, Vincent CA, Reen G, et al. Health Expect. 2023;26:51-63.
Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Wade C, Malhotra AM, McGuire P, et al. BMJ. 2022;376:e067090.
The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.
Amalberti R, Staines A, Vincent CA. Int J Qual Health Care. 2022;34:mzac006.
Leadership engagement is key to achieving patient safety goals. When it comes to improvement and innovation, healthcare organizations must balance multiple, sometimes conflicting, aims, such as cost, clinician wellbeing, and patient safety. This commentary outlines how healthcare organizations can manage multiple complex aims in relation to improvement and innovation projects. Four principles of managing multiple aims and five key strategies for practical action are described.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
The July effect is a phenomenon that presumably results in poor care due to the annual en masse introduction of new doctors into practice. This commentary outlines factors undermining the safe influx of these new clinicians into active, independent practice. The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child. 2021;106:333-337.
In the second of a two-part series, using examples from newborn units, the authors present a framework for supporting practitioners in low-resource settings to improve patient safety across four areas: (1) prioritizing critical processes, (2) improving the organization of care, (3) control of risks, and (4) enhancing responses to hazardous situations.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106:326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the Systems Engineering Initiative for Patient Safety (SEIPS) framework to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. BMC Med. 2020;18:340.
Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
Wu AW, Buckle P, Haut ER, et al. J Patient Saf Risk Manag. 2020;25:93-96.
This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care. In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Wæhle HV, Haugen AS, Wiig S, et al. BMC Health Serv Res. 2020;20.
This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies. Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.
Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.
Nawaz RF, Page B, Harrop E, et al. Arch Dis Child. 2020;105:446-451.
This analysis of 220 national incident data from England and Wales’ National Reporting and Learning System sought to identify safety concerns experienced by children on long-term ventilation at home. The most common problems were with the equipment and devices (e.g., faulty or damaged equipment) or procedures and treatment (e.g. tracheostomy tube becomes dislodged). The reports clearly stated harm to the child in 41% of incidents, such as emergency tracheostomy change or hospital admission. Identified contributory factors involved the patients, staff performance, family caregivers, equipment, organizational, and environmental features.
Amelung D, Whitaker KL, Lennard D, et al. BMJ Qual Saf. 2019;29:198-208.
… did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment … testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer. …
Amalberti R, Vincent CA. BMJ Qual Saf. 2020;29:60-63.
Health care is considered a high-risk industry due to clinical, administrative, economic, and regulatory stressors. This review explores a range of approaches to managing the safety of patients in this complex environment. The authors suggest that acceptance of the inability to eliminate all risk, focus on known problems, and engagement of all managerial levels is required to improve reliability.