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.
Folcarelli P, Hoffman J, Janes M, et al. J Healthc Risk Manag. 2023;43:26-31.
Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
Bourgeois FC, Fossa A, Gerard M, et al. J Am Med Inform Assoc. 2019;26:1566-1573.
OpenNotes enables patients and their designated caregivers to access medical records and provider documentation. Research has shown that this access may have the potential to improve medication adherence and patient engagement, and that patients may be able to identify errors in documentation. In this study performed at three distinct medical centers, researchers evaluated the effects of implementing a system for patients and families to report mistakes they saw in outpatient documentation. Of the 1440 reports obtained, 27% suggested possible inaccuracies and frequently prompted a change in the medical record. Symptom descriptions, past medical history, and medications were most commonly identified as areas of potential discrepancy by patients and families. An Annual Perspective discussed mechanisms for engaging patients as partners in safety.
Herlihy M, Harcourt K, Fossa A, et al. Obstet Gynecol. 2019;134:128-137.
Prior research has shown that when patients have access to clinicians' notes, they may identify relevant safety concerns. In this study, 9550 obstetrics and gynecology patients were provided with access to their outpatient visit documentation. Almost 70% of eligible patients read one or more notes during the study period, but only 3.2% shared feedback through 232 electronic reports. Of patients who provided feedback, 27% identified errors in the documentation; provider reviewers determined that 75% of these could impact care.
Kachalia A, Sands K, Van Niel M, et al. Health Aff (Millwood). 2018;37:1836-1844.
Health care systems have implemented communication-and-resolution programs (CRPs) to respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error disclosure, investigation into the cause, an apology, and early compensation. Some systems have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that CRPs will increase malpractice costs has limited widespread implementation. Investigators analyzed malpractice costs at four hospitals that implemented CRPs compared with matched control hospitals. Communication-and-resolution programs had either a positive or neutral effect on all metrics including new claims rate, paid claims rate, and total liability costs. This analysis is the most robust to date supporting CRP programs as previous studies have lacked a control group. A previous PSNet interview with Michelle Mello discussed other intersections between patient safety and the law.
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.
Sokol-Hessner L, Folcarelli P, Annas CL, et al. Jt Comm J Qual Patient Saf. 2018;44:463-476.
Preventable harm encompasses both physical injury and emotional harm to patients and families. Increasingly, the Agency for Healthcare Research and Quality, researchers, and patient advocacy groups have focused on studying and preventing emotional harm. Researchers convened a multidisciplinary expert group to identify best practices for enhancing respect and reducing emotional harm in health care. The group determined 25 strategies, including leading with an emphasis on respect and dignity, promoting accountability, partnering with patients, and supporting frontline staff. They provide a list of practical tactics to shift health care organizations toward a more respectful and just culture. A PSNet perspective examined how to accelerate organizational culture change in health care.
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197:1389-1395.
This commentary explores the results of a multidisciplinary discussion on the intersection of "respect" and "dignity" as requirements of safe care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, which include the need to expand the research on respect in the intensive care unit and the value of responding to failures of respect as safety incidents to design mechanisms for improvement.
Bell SK, Folcarelli P, Fossa A, et al. J Patient Saf. 2018;17:e791-e799.
Safety issues are common in the ambulatory care setting, but they can be difficult to detect because patients may spend months between contacts with the health care system. Engaging patients in their care is a recommended strategy to improve ambulatory safety and is the focus of a recent AHRQ toolkit. The OpenNotes initiative—in which patients have the opportunity to review and edit their medical records contemporaneously—aims to improve patient engagement and patient safety through promoting transparency. In this study, patients and caregivers with OpenNotes access were surveyed regarding the perceived effect of accessing notes on their understanding of their medical conditions and the patient–clinician relationship. Overall, most participants felt that accessing OpenNotes facilitated their understanding of the rationale for tests and referrals and improved their relationship with primary care providers. Although hindered by a low response rate, this study provides some support for the proposition that increased transparency can enhance patient engagement.
Lucier D, Folcarelli P, Totte C, et al. Jt Comm J Qual Patient Saf. 2018;44:84-93.
Mortality reviews, in which all cases of in-hospital death are discussed in structured format, can detect patient safety problems. This study reports the results of a mortality review survey in hospital medicine and intensive care units at an academic medical center. The survey aimed to identify deaths that merited further investigation. Researchers identified five deaths that would not have come to light through other hospital case review mechanisms. Respondents expressed needs for both clinician support following patient deaths and greater advance care planning. The authors conclude that frontline care team surveys can augment existing hospital mortality review processes. Previous WebM&M commentaries have highlighted the importance of advance care planning, particularly for seriously ill older patients and those with advanced dementia.
Mello MM, Kachalia A, Roche S, et al. Health Aff (Millwood). 2017;36:1795-1803.
Communication-and-resolution programs, in which health systems and liability insurers disclose errors, apologize, and offer compensation to patients and families, led to declines in malpractice costs in prior studies. However, some have raised concerns that actual implementation of these programs may not have the same benefits. This prospective observational study reports results following implementation of a communication-and resolution-program at four hospitals in Massachusetts. Investigators report that the program was largely implemented as intended. Less than 10% of events met criteria for compensation, and the median payment was $75,000, allaying concerns about high costs of these programs. Lawsuits occurred in 5% of cases. The authors conclude that these results support further implementation and evaluation of communication-and-resolution programs. A recent PSNet interview with Michelle Mello, the lead author of this study, discussed legal issues in patient safety.
Sokol-Hessner L, Folcarelli P, Sands KEF. BMJ Qual Saf. 2015;24:550-3.
Health care–associated harm can be physical, financial, or emotional. Advocating for increased focus on emotional harm resulting from insufficient respect for patients, this commentary reviews a conceptual framework developed by a multidisciplinary panel and recommends that institutions promote voluntary reporting of these harms, work to understand the severity of harm, and determine accountability when these events occur. The authors encourage health professionals to address emotional harms with the same rigor that has been applied to physical harms. Patient-centered care has been proposed as a strategy for reducing preventable harms.
Howell MD, Ngo L, Folcarelli P, et al. Crit Care Med. 2012;40:2562-8.
A rapid response team model that relied on clinical triggers to summon the primary team caring for the patient—rather than a dedicated, separate team—resulted in sustained reductions in unexpected inpatient mortality over a 4-year period.