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.
Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.
Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.
Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2022;5:15-25.
Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.
George J, Parker VA, Sullivan JL, et al. Health Care Manag Rev. 2020;45:E56-E67.
In this qualitative study, researchers applied an organizational learning perspective to characterize the various approaches used by four Veterans Health Administration hospitals to determine their patient safety priorities.
Zacher JM, Cunningham FE, Zhao X, et al. Am J Health-Syst Pharm. 2018;75:1460-1466.
Look-alike and sound-alike medications are known to increase the risk of adverse drug events. Using Veterans Affairs administrative data on prescriptions filled for look-alike and sound-alike medications, researchers found that the potential for medication errors was high, but the actual error rate based on chart review was low.
Sullivan JL, Shin MH, Engle RL, et al. Jt Comm J Qual Patient Saf. 2018;44:663-673.
Reducing readmissions remains a major patient safety priority. Project Re-Engineered Discharge (RED) was designed to improve the hospital discharge process. This qualitative study evaluated the implementation of Project RED across five Veterans Health Administration hospitals.
Mull HJ, Graham LA, Morris MS, et al. JAMA Surg. 2018;153:728-737.
Readmissions occur frequently after hospital discharge and may reflect opportunities to improve the quality and safety of care provided during the index admission. Using a modified Delphi process, an expert panel reviewed 30-day postoperative readmissions over a 7-year period for patients who had received surgery within the Veterans Affairs system. The study suggests that more than 50% of postoperative readmissions may be related to the quality of surgical care provided during the index admission.
Nix M, McNamara P, Genevro J, et al. Health Aff (Millwood). 2018;37:205-212.
Learning collaboratives are multimodal interventions that are often used to implement evidence-based practices. This perspective from AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type of positive change; communication among members; duration and sustainability; and social systems, or the organization and culture of the collaborative. The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions employ this taxonomy.
Mull HJ, Rosen AK, O'Brien WJ, et al. Health Serv Res. 2018;53:3855-3880.
The Veterans Affairs Surgical Quality Improvement Program (VASQIP) and the private sector National Surgical Quality Improvement Program have transformed both safety measurement and quality in surgery. Historically, VASQIP has placed comparatively little emphasis on outpatient surgical safety. This study examined trends in hospital admission within 7 days of all outpatient surgeries performed among veterans age 65 and older in the United States. Researchers found that 16% of these procedures were associated with 7-day admission, higher than what has been observed in younger, healthier patients. Common reasons for admission included surgical, medical, or device complications and inability to secure safe aftercare at home. The authors posit that, while not every admission represents a preventable adverse event, measurement is a critical step toward improving outpatient surgical safety. A recent PSNet interview and perspective explored the evolution of surgical patient safety.
This qualitative study asked surgical staff about risk factors for adverse events in outpatient surgery. Respondents identified safety vulnerabilities including patient adherence, equipment, safety culture, and postoperative instructions and care. The authors suggest further research on these topics with regard to outpatient surgery.
Chen Q, Rosen AK, Borzecki A, et al. Health Serv Res. 2016;51:2140-2157.
The AHRQ Patient Safety Indicators (PSIs) use hospitals' administrative data to measure quality and carry financial consequences for hospitals as part of pay-for-performance initiatives. Prior research has raised concerns about the validity of PSIs compared with directly using clinical data to identify safety events. AHRQ recently restructured PSI-90 (a composite measure containing multiple distinct PSIs) from volume-based to harm-based weighting. Using data from 132 Veterans Health Administration hospitals, this retrospective study compared hospital performance using the previous PSI-90 with performance under the redesigned measure. Although there was strong association between the volume-based and harm-based PSI-90 measures, use of the harm-based version had a significant impact on pay-for-performance because of changes in the weights of the component measures. Approximately 15% of hospitals in the study would face changes in financial penalties under the Hospital-Acquired Condition Reduction Program when using the new PSI-90. A past PSNet perspective discussed the impact of pay-for-performance.
Sullivan JL, Rivard PE, Shin MH, et al. Jt Comm J Qual Patient Saf. 2016;42:389-411.
High reliability organizations operate in high-hazard domains with consistently safe conditions. Through individual interviews, investigators determined that staff perceptions of patient safety largely matched their conceptual model of a high reliability health care organization and found two additional characteristics: teamwork and systems approaches to improvement. The authors suggest their model of high reliability organizations can be used to assess organizational reliability.
Even though disclosure of medical errors reduces litigation and patient distress, many providers remain uncomfortable with disclosing and apologizing for errors. In this survey of 67 surgeons across 3 medical centers, most reported prompt disclosure of adverse events. Surgeons who had difficult disclosure conversations experienced more anxiety. These results highlight the continued importance of supporting providers who experience emotional distress after medical errors.
Hatoun J, Chan J, Yaksic E, et al. Am J Med Qual. 2017;32:237-245.
Progress in patient safety has been limited by a lack of reliable measures. This problem is compounded in ambulatory care, as most existing metrics have sought to measure safety in hospitalized patients. This systematic review identified 182 published safety measures in primary care and categorized them according to Donabedian's triad and the safety target. The majority of metrics sought to measure safety in medication management, with laboratory testing and care coordination among the other types of safety issues being assessed. The authors note several limitations with the metrics they identified—most had not been validated, and there were no published measures identified for diagnostic error (despite increasing evidence that such errors are common in the outpatient setting). A PSNet interview discusses the challenges of measuring and improving safety in the ambulatory care environment.
Stall NM, Fischer HD, Wu F, et al. Medicine (Baltimore). 2015;94:e899.
This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.
Trigger tools have been shown to be an efficient way to screen for adverse events. This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient setting. Five of the triggers performed reasonably well for either detecting harm or leading to a change in care plan.
Chen Q, Shin MH, Chan J, et al. Am J Med Qual. 2016;31:178-86.
This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.
Shin MH, Sullivan JL, Rosen AK, et al. Med Care Res Rev. 2014;71:599-618.
The AHRQ Patient Safety Indicators (PSIs) are increasingly used as publicly reported measures of hospital quality performance. This study investigated Veterans Health Administration hospitals with low and high PSI composite scores. Although high performers exhibited some distinctions in leadership and communication, overall the relationship between PSI score and organizational processes was inconsistent.
Mull HJ, Borzecki A, Loveland S, et al. Am J Surg. 2014;207:584-95.
There is consensus that multiple methods must be used in order to detect adverse events during hospitalization. This study found that the AHRQ Patient Safety Indicators had poor sensitivity for identifying preventable harm in surgical patients when compared directly to the National Surgical Quality Improvement Program methodology.