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.
Zuckerman RB, Maddox KEJ, Sheingold SH, et al. N Engl J Med. 2017;377:1551-1558.
Under the Centers for Medicare and Medicaid Service Hospital Readmissions Reduction Program, hospitals are subject to nonpayment if patients with certain medical conditions are readmitted. Research supports the effectiveness of this program in decreasing readmissions and some have argued for expansion to a hospital-wide readmission measure. Using Medicare claims data, investigators concluded that transitioning to a hospital-wide readmission measure would lead to greater penalties for safety-net hospitals compared to other hospitals, a concern that has been raised with regard to Medicare's Hospital-Acquired Condition Program.
Zuckerman RB, Sheingold SH, Orav J, et al. N Engl J Med. 2016;374:1543-51.
The Centers for Medicare and Medicaid Service's policy on nonpayment for certain hospital readmissions has reduced their incidence. However, this policy change may have unintended consequences. One possible outcome is an increased number of patients who return to the hospital being placed on observation status. Comparing readmission rates and observation stays for targeted and nontargeted conditions, this secondary data analysis examined how observation stay rates changed in parallel with readmission rates. The authors found that readmissions decreased, consistent with prior studies, and observation stays increased. Interestingly, a within-hospital analysis determined that the decline in readmissions was not explained by an increase in observation stays. This finding should allay concerns about this specific unintended consequence of the readmission policy, although other issues such as length of stay changes should be addressed.
Weissman JS, López L, Schneider EC, et al. Int J Qual Health Care. 2014;26:129-35.
A recent systematic review found that better patient experiences of care are associated with improved patient safety and quality of care. This survey of more than 2500 adults discharged from 16 hospitals in Massachusetts adds to our understanding of this relationship. Patients who self-reported having experienced an adverse event (AE) while hospitalized rated the overall quality of hospital care lower, but this finding was primarily among patients who did not report that the AE they experienced was explicitly disclosed to them. Among patients who experienced an AE, it appeared that patient satisfaction was highest (and nearly equal to satisfaction of patients with error-free hospitalizations) when the error was disclosed, the patients were engaged in their own care, and discharge was perceived as timely. These findings imply that even when patients experience complications, "service recovery" efforts, such as formal error disclosure programs, can positively affect patients' perceptions of the care quality.
Zhu J, Stuver SO, Epstein AM, et al. Med Care. 2011;49:948-55.
Traditional methods of error detection have relied mainly on provider input or administrative data, without emphasizing the role of the patient in safety. This study of more than 2000 patients recently discharged from Massachusetts hospitals found that patients could identify unique adverse effects of hospitalization that may not have been identified by other methods. Importantly, physician reviewers agreed that the patient-reported events constituted a true clinical adverse event in more than 70% of cases. This finding corroborates prior research showing that patient-reported adverse events provide an important complementary perspective in assessing organizational safety problems.
Jha AK, Epstein AM. Health Aff (Millwood). 2010;29:182-7.
This study surveyed more than 700 board chairs and found that fewer than half rated quality as one of their top two priorities. Few board chairs reported any dedicated training in quality, and large differences were present between board activities in high-performing versus low-performing hospitals. The latter provides opportunities for future intervention and policy change.
Fowler FJ, Epstein AM, Weingart SN, et al. Jt Comm J Qual Patient Saf. 2008;34:583-90.
This survey of patients discharged from 16 hospitals in Massachusetts sought to determine patients' perceptions of adverse events during hospitalization. Prior work in this area has demonstrated that patients can identify adverse events that were not documented in the medical record. One in four patients reported experiencing an adverse event during hospitalization, and most of these resulted in significant health consequences. A growing body of literature shows that patient surveys are an important method of detecting adverse events, and involving patients in safety efforts is a key component of providing patient-centered care.
Jha AK, Orav J, Ridgway AB, et al. Jt Comm J Qual Patient Saf. 2008;34:318-325.
The Leapfrog Group is a consortium of private and public employers who collectively purchase health care for more than 30 million Americans. Leapfrog recommends four evidence-based practices for implementation by hospitals: computerized provider order entry, intensivist coverage of critically ill patients, evidence-based hospital referral for high-risk patients, and adoption of the National Quality Forum's safe practices. This study found that hospitals that reported implementing at least one patient safety practice also provided slightly better care for myocardial infarction and congestive heart failure (as measured by publicly reported quality data), but not for pneumonia. The authors note that as the Leapfrog recommended practices are not directly tied to improving care quality for these specific conditions, implementation of Leapfrog patient safety practices likely indicates an overall commitment to providing higher-quality care.
Weissman JS, Schneider EC, Weingart SN, et al. Ann Intern Med. 2008;149:100-108.
While many methods exist for detecting inpatient adverse events, ranging from medical record review to incident reporting, no single method is considered optimal. Patient involvement in safety efforts is being actively promoted, but current efforts have focused on empowering patients to help prevent errors. This study attempted to detect adverse events by surveying patients recently discharged from the hospital, and compared patients' reports with review of their medical records. Patients reported multiple preventable errors that were not identified in medical record review, as well as additional adverse events that occurred after discharge. The concern that patients may not be able to differentiate between poor service quality and adverse events was not borne out in this study. The authors recommend that hospitals consider adding questions about adverse events to existing patient satisfaction surveys.
Weissman JS, Annas CL, Epstein AM, et al. JAMA. 2005;293:1359-66.
In order to better understand the opinions and experiences of hospital leaders with mandatory state reporting systems, this survey study collected data from a random sampling of chief executive and chief operating officers. Results demonstrated substantial concern about the impact of these systems on internal reporting systems and the potential for encouraging litigation while limiting patient safety efforts. Vignettes illustrating hypothetical errors and the types of errors most and least likely to be reported are included. The authors discuss challenges in balancing the importance of reporting systems with the legal and regulatory factors that likely foster the findings in this study.
Weingart SN, Zhu J, Chiappetta L, et al. Int J Qual Health Care. 2011;23:269-77.
Hospitalized patients who reported a higher level of participation in their own care—for example, a greater understanding of their diagnoses—had a lower incidence of adverse events during hospitalization.