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.
Talcott WJ, Lincoln H, Kelly JR, et al. Pract Radiat Oncol. 2020;10:312-320.
Peer review of radiation oncology patient treatment plans can help prevent harm and reduce errors. In this prospective blinded study, researchers generated treatment plans with simulated errors and randomly inserted these treatment plans into weekly chart rounds to assess the effectiveness of peer review on error detection. Overall detection rate of clinically significant problematic plans was 55%. The authors suggest that error detection could be significantly improved by shortening chart rounds and routine insertion of problematic plans into rounds.
Mazurenko O, Andraka-Christou BT, Bair MJ, et al. Jt Comm J Qual Patient Saf. 2019;45:241-248.
This interview study examined perspectives from nurses, physicians, and administrators about balancing adequacy of pain management with risks of opioid medications. Key strategies for minimizing opioid use included offering alternatives to opioids, setting feasible expectations for pain management, and using a team approach.
Mazurenko O, Richter J, Kazley AS, et al. J Patient Saf. 2021;17:e1537-e1545.
Prior research has shown that managers and leaders often have a more positive view of safety culture compared to frontline staff. Using data from the 2010–2011 AHRQ Medical Office Survey on Patient Safety Culture, researchers found that perceptions of safety climate differed across medical practice owners and frontline staff, with managers bearing ownership responsibility having the more favorable view.
Learning from adverse events is a core component of patient safety improvement. This review explores the application of this concept in radiation oncology, successful practices, and challenges for incident learning system implementation in the specialty.
Richter J, Mazurenko O, Kazley AS, et al. J Patient Saf. 2020;16:289-293.
Managers' perceptions of safety culture tend to be more positive than frontline health care workers. This study found that in hospitals where manager and frontline perceptions of safety culture were more aligned, processes of care for conditions such as acute myocardial infarction were better compared to hospitals where safety culture diverged more between management and staff.
Mazurenko O, Richter J, Kazley AS, et al. Health Care Manage Rev. 2019;44:79-89.
Establishing a climate of safety is essential for improving safety in hospitals. Although a robust safety climate is associated with measurable improvements in safety, the question remains whether patients perceive their care differently in hospitals with a stronger safety culture. This cross-sectional study used data from the AHRQ Hospital Survey on Patient Safety Culture (HSPSC) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to examine the relationship between safety culture and patient satisfaction with care. Investigators found a moderately strong association between HSPSC and HCAHPS scores, indicating that hospitals with a more robust culture of safety also had higher patient satisfaction scores. This correlation was particularly strong for the teamwork and communication domains of the HSPSC, indicating that improvement in relationships between staff may translate to enhanced communication with patients. A prior multinational study also found a positive association between nurses' perception of care quality and patient satisfaction. A recent PSNet interview discussed recent advancements in understanding safety culture.
Beauvais B, Richter J, Kim FS. Health Care Manage Rev. 2019;44:2-9.
Experts have argued for a business case for patient safety, but studies of economic outcomes and patient safety have been mixed. This retrospective, cross-sectional study sought to determine whether hospital safety was associated with hospital financial outcomes by analyzing Leapfrog Hospital Safety Score data and American Hospital Association data on operating income, operating margin, and net patient revenue. This study included more than 2200 hospitals in the United States. After adjusting for factors affecting both safety and finances (such as hospital size, teaching status, rural versus urban location, and payer mix), investigators found that hospitals with better financial performance were likely to have a higher safety rating. The authors suggest that promoting patient safety leads to improved financial outcomes; however, it is equally possible that financially stable hospital systems invest more in preventing adverse events and promoting safety. A past PSNet perspective discussed efforts to promote the business case for patient safety.
Richter J, McAlearney AS. Health Care Manag Rev. 2018;43:42-49.
The Comprehensive Unit-based Safety Program (CUSP) reduced central line–associated bloodstream infections (CLABSI) in intensive care units nationwide, but its effectiveness varies among settings. This analysis found that units with a strong safety culture had greater success in lowering CLABSI with CUSP implementation than units with a worse safety culture. The authors suggest addressing a unit's safety culture prior to implementing CUSP to augment its impact.
Ford E, Silvera GA, Kazley AS, et al. Int J Health Care Qual Assur. 2016;29:614-27.
The effects of electronic health record (EHR) implementation on safety culture are unclear. EHR adoption is disruptive to clinician workflow, affecting work satisfaction and increasing physician and nurse burnout. This could plausibly manifest as worsened safety culture after EHR implementation. In this study, which used AHRQ Hospital Survey on Patient Safety Culture data at 190 hospitals between 2007 and 2011, EHR adoption was associated with mixed effects on safety culture. No overall relationship was found between EHR implementation and safety culture. In fact, fewer patient safety events were reported following EHR adoption, which may reflect safer care or conversely could represent challenges with reporting events in the electronic systems. Early adopters of EHRs did appear to have a stronger culture of safety, but this finding could either mean that EHRs improved safety or that hospitals that emphasized other measures to improve safety culture also tended to adopt EHRs earlier. As this study illustrates, the profound workflow shifts associated with EHR implementation likely induce complex effects that could improve or impair safety. A previous PSNet interview described the role of health information technology in patient safety.
Richter J, McAlearney AS, Pennell ML. Health Care Manage Rev. 2016;41:32-41.
Incomplete handoffs and insufficient communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This analysis of data from the AHRQ Hospital Survey of Patient Safety Culture sought to determine how perceptions of organizational factors that affect safety can contribute to optimal handoffs. Perceived teamwork across units was a significant predictor for successful handoffs. Perceptions of staffing adequacy and management support for patient safety efforts were also related to good handoffs. Among frontline staff, open communication was associated with optimal handoffs, while among management safe handoffs were linked to a continuous learning culture. These findings add to existing studies which underscore the need for high-reliability organizations to promote safety efforts. The authors advocate for hospital leadership to promote teamwork and open communication to augment handoffs in their facilities. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.
Richter J, McAlearney AS, Pennell ML. Am J Med Qual. 2015;30:550-8.
Voluntary error reporting is a critical mechanism for identifying patient safety issues in an organization. However, the process is dependent on a culture of safety that enables providers to report mistakes and near misses. This study used the AHRQ Hospital Survey on Patient Safety Culture comparative database to test organizational factors that may predict more robust error reporting. Error feedback and organizational learning were most associated with perceptions of frequent error reporting, supporting the importance of hospitals demonstrating that reports are seriously considered and acted upon. Some manager respondents did not seem to recognize the significance of perceived management support in enabling error reporting. A prior AHRQ WebM&M perspective discussed the establishment of a safety culture in health care organizations.
Ford E, Smith K, Harris K, et al. Med Phys. 2012;39:6968-71.
Analysis of voluntarily reported errors in radiation therapy treatments resulted in systematic changes to treatment planning and delivery. After the system improvements were implemented, no similar errors occurred and multiple near misses were detected before patients were affected.
Teufel RJ, Kazley AS, Basco WT. Clin Pediatr (Phila). 2009;48:389-96.
This national survey conducted in 2003 found that only 6% of pediatric inpatient units were using computerized provider order entry (CPOE). Dedicated children's hospitals and teaching institutions were more likely to use CPOE.
Menachemi N, Ford E, Beitsch LM, et al. Am J Med Qual. 2007;22:319-26.
Adoption of electronic health records (EHR) in hospitals and ambulatory practices has been slow, despite recommendations from influential organizations and popular support. This survey of outpatient practices in Florida investigated the adoption of EHR and the specific features used by practices with an EHR. Only one quarter of practices surveyed had implemented an EHR, and among those, most did not use more advanced features such as computerized provider order entry or clinician decision support. The authors discuss the implication of these findings in the context of sociological models of technology adoption.
Menachemi N, Ford E, Chukmaitov A, et al. Am J Manag Care. 2006;12:738-744.
The authors surveyed primary care physicians on their use of computerized physician order entry (CPOE) and found that managed care involvement, physician age, practice size, and multidisciplinary affiliations correlated with CPOE use.