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.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Bion J, Aldridge CP, Girling AJ, et al. BMJ Qual Saf. 2021;30:536-546.
In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.
Meddings J, Saint S, Lilford RJ, et al. NEJM Catalyst. 2020;1.
This article describes the evolution of the “zero harm” campaign, challenges in measuring preventable harm, and potential harms of zero-harm initiatives (e.g., misclassifying preventable events, failing to consider opportunity costs).
Although electronic health records have addressed some patient safety concerns, they have also introduced new risks. In this survey study in oncology, nearly 300 individuals, including physicians, nurse practitioners, and nurses, completed a survey ranking their practice's reliance on the electronic health record (from 1= "all paper" to 5= "all electronic") and measuring safety culture and quality of clinician–clinician communication. Investigators found that individuals describing a greater degree of electronic health record use reported lower safety culture scores, and individuals who rated communication higher also perceived safety culture as more optimal. The authors suggest that challenges to electronic health record use may affect oncology practitioners' perceptions of safety. A previous PSNet interview discussed the role of health information technology in patient safety.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019;28:741-749.
This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.
Manaseki-Holland S, Lilford RJ, Te AP, et al. Milbank Q. 2019;97:228-284.
Measuring patient safety remains an ongoing challenge. This systematic review examined whether preventable death rates could be used as a measure of hospital quality. Researchers reviewed 23 studies and found that estimates of preventable in-hospital death are consistently low. Ascertainment of preventability was not consistent across multiple clinician-reviewers, and the authors estimate that cases would need review by eight or more clinicians to achieve the precision required. The authors conclude that preventable death rates would not be a valid or reliable measure of patient safety. A past PSNet interview discussed the development of hospital standardized mortality ratios and their role in monitoring performance.
Manojlovich M, Frankel RM, Harrod M, et al. BMJ Qual Saf. 2019;28:160-166.
Researchers describe the use of video reflexive ethnography to improve communication between physicians and nurses during rounds at a single academic medical center. They conclude that video reflexive ethnography is feasible and may have the potential to improve communication between physicians and nurses.
Manojlovich M, Hofer TP, Krein SL. J Patient Saf. 2021;17:e732-e737.
Communication problems persistently contribute to medical error. This review focuses on the exchange of information between care team members. The authors describe an eight-element framework that targets trust, hierarchy, and technology as an approach to communication improvement that embraces the interpersonal nature of safe health care delivery.
Unprofessional and disruptive behavior among health care personnel can adversely impact safety, but reporting and addressing such behavior remains challenging. In this mixed-methods study, researchers identify barriers faculty may face when reporting student lapses in professionalism.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.
Hannawa AF, Frankel RM. J Patient Saf. 2021;17:e1130-e1137.
Effective error disclosure fosters a just culture. In this large study, participants responded to actors as they disclosed a minor error and a sentinel event. When physicians communicated their remorse nonverbally, participants had less desire to distance themselves from the physician or seek legal action.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28:74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Krein SL, Mayer J, Harrod M, et al. JAMA Intern Med. 2018;178:1016-1057.
Infection control precautions including use of personal protective equipment (PPE) are critical for preventing transmission of infections within health care settings. This direct observation study observed frequent failures in use of PPE, including entering rooms without using PPE at all, PPE process mistakes, and slips in properly executing PPE use. The authors suggest that given the wide range of failures, a variety of strategies are needed to improve use of PPE.
Chopra V, Harrod M, Winter S, et al. J Hosp Med. 2018;13:668-672.
This ethnographic study examined the process of making a diagnosis among academic inpatient medical teams. Investigators observed that diagnosis requires dialogue within team, needed data is often not available, and distractions and time pressure are frequent. These observations may inform future interventions to improve timeliness and accuracy of diagnosis.