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.
Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;329:1149-1150.
The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.
Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;182:720-728.
Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.
Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.
Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).
This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
Mendu ML, Lu Y, Petersen A, et al. BMJ Qual Saf. 2020;29.
This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.
Moore JS, Mello MM, Bismark M. Bioethics. 2019;33:948-957.
Patient engagement is now acknowledged as a cornerstone of patient safety, but the perspectives of patients who have experienced adverse events remain understudied. This interview study of 92 patients who had experienced iatrogenic injury identified several insights about the aftermath of adverse events. As with prior studies, researchers found that patients expressed a desire to be heard. Participants had positive perceptions of patient safety research and expressed a desire that others learn from the adverse event they experienced. The authors suggest that institutional review boards permit investigators to approach patients who have experienced adverse events to participate in studies, rather than prohibit such studies due to fear of causing further psychological harm. They also recommend that researchers discuss these adverse events with patients through a reciprocal lens, expressing support and sympathy rather than maintaining an emotionally distant stance. A previous PSNet interview with the lead author discussed disclosure and apology in health care.
Lacson R, Cochon L, Ip I, et al. J Am Coll Radiol. 2019;16:282-288.
This retrospective review of nearly 900 incident reports related to diagnostic imaging found that the most common type of safety problem was linked to the imaging procedure. Events associated with communicating abnormal results were less common but had a higher potential to harm patients. Most events had multiple contributing factors.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Studdert DM, Spittal MJ, Zhang Y, et al. N Engl J Med. 2019;380:1247-1255.
Malpractice claims can shed light on patient safety hazards. This observational study examined how paid malpractice claims affected physicians' practice. Investigators found that a small proportion of physicians, about 10%, had one or more paid malpractice claims, consistent with prior studies. Approximately 2% of physicians accounted for nearly 40% of paid claims. Physicians with paid claims were more likely to leave clinical practice and more likely to move to smaller practice settings. The authors raise the concern that physicians who move to smaller practice settings may lack the institutional and peer support to remediate their clinical skills and behavior. A PSNet perspective explored the risk of recurring medicolegal events among providers who have received multiple malpractice claims.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Gallagher TH, Mello MM, Sage WM, et al. Health Aff (Millwood). 2018;37:1845-1852.
Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.
Weiner SG, Price CN, Atalay AJ, et al. Jt Comm J Qual Patient Saf. 2019;45:3-13.
Multidisciplinary organizational efforts are necessary to reduce inappropriate prescribing of opioids. This commentary describes the design and implementation of an opioid stewardship program that combined the use of technology, education, and clinical strategies under strong leadership guidance as a cross-disciplinary strategy to address opioid misuse.
Cochon L, Lacson R, Wang A, et al. J Am Med Info Asso. 2018;25:1507-1515.
As the diagnostic safety field has matured, researchers are striving to better define the diagnostic process and identify failure modes that may lead to patient harm. This study utilized human factors engineering approaches to characterize the information sources used in radiologic diagnostic imaging according to the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Most potential errors were related to person-related factors, such as inadequate communication between clinicians, rather than technological factors.