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.
Alboksmaty A, Beaney T, Elkin S, et al. Lancet Digit Health. 2022;4:e279-e289.
The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71:e547-e554.
There has been an increased focus on patient safety, including missed diagnosis, in primary care in recent years. This cohort study evaluated the incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy, urinary tract infection or pulmonary embolism. Shorter duration of appointment and telephone appointment (compared with in person) were associated with increased incidence of self-referred emergency hospital admission.
Alboksmaty A, Kumar S, Parekh R, et al. PLoS One. 2021;16:e0248387.
Older adults, especially older adults with multimorbidities, are at increased risk of severe illness or death from COVID-19. General practitioners (GPs) in the UK were interviewed about how COVID-19 policies affected care of older adult patients with multimorbidities in their practices. Five major themes emerged: changes in primary care, involvement of GPs in policy making, communication and coordination, worries and stressors, and suggestions for improvement across the first four themes. COVID-19 policies have provided opportunities to continue providing safe healthcare for older adults with medical complexities, but they also highlight possible areas for improvement.
Cecil E, Bottle A, Esmail A, et al. BMJ Qual Saf. 2018;27:965-973.
Measuring hospital quality remains challenging, despite numerous public efforts. Inpatient mortality represents one measure of hospital quality. Researchers sought to assess the association between alerts generated by the Imperial College Mortality Surveillance System (a national hospital mortality surveillance system that generates monthly mortality alerts) and trends in the relative risk of mortality across National Health Service hospital trusts. On average, mortality risk decreased after a trust received a mortality alert. However, the authors conclude that random variation could account for the alerts and that a causal relationship cannot be determined. A past PSNet perspective discussed the use of risk-adjusted mortality as part of a safety measurement program.
Car LT, Papachristou N, Gallagher J, et al. BMC Fam Pract. 2016;17:160.
Medication errors remain a significant source of patient harm. Although many studies have focused on the hospital setting, less is known about ambulatory medication safety. In this study, primary care physicians were asked to identify three significant problems and solutions regarding medication errors in the outpatient setting. Investigators used an innovative approach to rank the problems and solutions described by the 113 clinician respondents in the study. The top three problems identified included incomplete medication reconciliation during a transition in care, insufficient education provided to patients on their medications, and inadequate discharge summaries. Standardizing discharge summaries, decreasing unnecessary prescribing, and avoiding polypharmacy were the three highest ranked solutions. A previous PSNet perspective discussed safety in ambulatory care.
Car LT, Papachristou N, Bull A, et al. BMC Fam Pract. 2016;17:131.
Compared with other patient safety issues, diagnostic errors have received little attention until recently. Missed or delayed diagnoses are a common reason for malpractice claims. This study sought to determine barriers and solutions to delays in diagnosis in primary care. Investigators sent a questionnaire to more than 500 clinicians and received 113 responses. Participants identified 33 discrete problems associated with delays in diagnosis and suggested 27 solutions. The main issues included inability to meet patients' care needs and inadequate communication between secondary and primary care. The top solutions included improving training of primary care doctors and enhancing communication among providers as well as between providers and patients, especially around test results. An Annual Perspective discussed diagnostic errors in more detail.
King A, Bottle A, Faiz O, et al. Ann Surg. 2017;265:910-915.
Nearly 2 decades into the patient safety movement, measurement of safety events remains a challenge. In particular, methods to measure safety that are patient-centered and can be compared across organizations are not standardized. This study proposes adverse event–free admissions as a potential measure of safety, defining the term as any hospitalization in which the patient does not experience a preventable adverse event. In analyzing nearly 24 million Medicare admissions, investigators found that only 64% were adverse event-free. When evaluating admissions for colorectal surgical procedures, the authors were able to identify a subset of hospitals with markedly higher rates of adverse events using this metric, implying that the measure may be suitable for interhospital comparisons. The recent National Patient Safety Foundation report, Free From Harm, identified safety measurement as a high priority for the field, and this study is a promising step forward. A previous PSNet perspective discussed challenges associated with safety measurement.
Ruiz M, Bottle A, Aylin PP. BMJ Qual Saf. 2015;25.
The weekend effect is a well-documented phenomenon across a range of health care outcomes. This study found worse outcomes following elective surgery done on Friday, Saturday, or Sunday compared with other days of the week, even after adjusting for patient, provider, and hospital factors. This work adds evidence to the depth and breadth of the weekend effect.
Samra R, Bottle A, Aylin PP. BMJ Open. 2015;5:e008128.
This study reviews insights from interviews of primary care physicians, practice nurses, practice managers, and members of clinical governing bodies and regional patient safety teams in London. The participants described many barriers to patient safety in primary care and offered specific recommendations for improving the use of data and patient safety monitoring.
Ruiz M, Bottle A, Aylin PP. BMJ Qual Saf. 2015;24:492-504.
The weekend effect of worse patient outcomes when admissions or procedures occurred outside of usual business hours has been documented across multiple care settings. In this analysis of pooled hospital administrative data across four countries, in-hospital mortality within 30 days of admission or surgical procedure was higher for patients admitted from the emergency department or undergoing interventions during the weekend, although there were specific differences by country. This consistency suggests that challenges with current weekend structure at hospitals should be examined across a broad range of clinical services and delivery models. An accompanying editorial suggests that the existence of the weekend effect is no longer in dispute and urges efforts toward identifying and addressing its underlying causes.
Palmer WL, Bottle A, Davie C, et al. Arch Neurol. 2012;69:1296-302.
Multiple prior studies have identified increased mortality, preventable complications, and delays in undergoing urgent procedures for patients admitted to the hospital on the weekend. This phenomenon has been termed the "weekend effect." With this large, retrospective cohort study, evidence of inferior weekend care now includes patients with acute stroke. The study, which involved nearly 100,000 stroke patients admitted to hospitals in the United Kingdom, found significantly lower performance across 5 of 6 quality and safety indicators for patients admitted on the weekend. Most notably, the rate of 7-day in-hospital mortality for Sunday admissions was 11.0%, compared with 8.9% for weekday admission. The authors note that 350 in-hospital deaths may be avoidable each year if care provided on weekends equaled that provided on weekdays.
Tsang C, Palmer WL, Bottle A, et al. Am J Med Qual. 2012;27:154-69.
The AHRQ Patient Safety Indicators (PSIs) screen administrative data to identify cases of potential adverse events. This review analyzes studies of PSIs and other administrative data screening tools to identify how to refine the accuracy of these tools.
Aylin PP, Yunus A, Bottle A, et al. Qual Saf Health Care. 2010;19:213-7.
Differences in weekend care for hospitalized patients have been reported. These differences include not only overall complications but also delays in undergoing urgent procedures, survival from in-hospital cardiac arrest, and mortality from acute myocardial infarction. This study adds to the existing literature by analyzing more than 4 million emergency department admissions to provide a broader view of the relationship between weekend admissions and clinical outcomes. Investigators discovered that patients admitted during the weekend experienced a 10% higher odds of death. The study also reported that for the 50 diagnosis groups with the highest number of deaths, 17 were associated with a significantly higher odds of mortality if admitted on a weekend. The authors estimate that nearly 3400 excess deaths during 2005-2006 could be attributed to weekend care, which exceeds the number of deaths from road accidents in Great Britain in 2006—an admittedly crude but striking comparison.
Vincent CA, Aylin PP, Franklin BD, et al. BMJ. 2008;337:a2426.
This commentary reflects on data from the United Kingdom's National Health Service to underscore the current inadequacy of methods to measure safety. Similar to a past commentary from the United States, the authors call for more systematic data collection strategies that will better monitor and track progress in patient safety.