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.
Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;31:716-724.
Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.
Catalanotti JS, O’Connor AB, Kisielewski M, et al. J Gen Intern Med. 2021;36:1974-1979.
Overnight coverage creates opportunities for increasing resident autonomy but can carry risks for patient safety. This study found that the presence of overnight hospitalists was associated with fewer resident barriers to contacting supervising physicians overnight but that other barriers during overnight coverage – such as technological barriers and organizational culture – influence residents seeking help from supervising physicians.
Maatman TC, Prigmore H, Williams JS, et al. BMJ Qual Saf. 2019;28:934-938.
This educational intervention used a comic book format to convey patient safety concepts to internal medicine residents. Awareness and confidence in patient safety topics including medication safety and fall prevention improved on the post-test compared to the pre-test, suggesting this modality has promise as a patient safety education tool.
Nanchal R, Aebly B, Graves G, et al. BMJ Qual Saf. 2017;26:987-992.
Communication errors during handoffs can lead to patient harm. Standardizing the handoff process has been shown to improve patient safety. This prospective trial demonstrated that implementation of a standardized intensive care unit sign-out process among residents led to fewer unexpected patient events and unplanned interventions.
Fletcher KE, Singh S, Schapira MM, et al. Am J Med. 2016;129:341-7.e21.
This prospective cohort study across three sites with an internal medicine residency program found no relationship between resident discontinuity and adverse events. Safe handoffs have become even more essential in the era of resident duty hour restrictions.
Lamba R, Linn K, Fletcher KE. BMJ Qual Saf. 2014;23:667-9.
Although this direct observation study found that medical team rounds usually include conversation about patient safety concerns, appropriate mitigating action was discussed for only 50% of issues. The authors highlight how rounds offer an opportunity to detect potential risks and educate teams about patient safety in real time.
… to overcome. Studying important patient outcomes (e.g., mortality) is difficult, because of the (fortunately) … right will hopefully also help us get the answers right. … KathlynE. Fletcher, MD, MA … Associate Professor of MedicineClement J. …
This article discusses evidence surrounding the impact of resident duty hour limits on safety in health care.
Christopher P. Landrigan, MD, MPH, of Brigham and Women's Hospital has performed key studies on how sleep deprivation affects clinicians and strategies to mitigate such fatigue to improve patient safety, including seminal articles published in the New England Journal of Medicine in 2004 and 2010.
Fletcher KE, Reed DA, Arora V. J Gen Intern Med. 2011;26:907-919.
This systematic review of the effect of physician duty hour regulations found that the regulations were associated with improved resident well-being, but had mixed effects on resident educational outcomes and clinical outcomes.
Reed DA, Fletcher KE, Arora V. Ann Intern Med. 2010;153:829-42.
Duty hour regulations that take effect in July 2011 will limit first-year residents' shift length to 16 hours, cap the consecutive night shifts that can be worked, and encourage protected sleep time. This systematic review found that while reducing shift length has some effect on patient safety, existing literature does not indicate the optimal shift length or the magnitude of benefit for patients or physicians. A past AHRQ WebM&M perspective and interview discussed the role of medical education in improving patient safety.
Fletcher KE, Wiest FC, Halasyamani L, et al. J Gen Intern Med. 2008;23:623-8.
Resident work hours, fatigue, and discontinuity in care continue to be significant areas of concern in patient safety. This study surveyed inpatients from three different types of institutions to highlight the knowledge, concerns, and attitudes expressed by patients around these issues. Investigators were surprised to learn that the majority of patients were in fact not concerned about either fatigue or discontinuity despite media attention given to these topics. However, trust in physicians and satisfaction were related to the degree of concern about fatigue and discontinuity. Such perceptions among patients may be important in guiding future efforts to ensure patient-centered care.
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-8.
This case study presents the events surrounding the death of a woman admitted to an academic medical center with pancreatitis. The discussion analyzes the sequence of errors that transpired from initial delays in diagnosis and treatment to poor communication and handoffs (the latter is a 2007 National Patient Safety Goal). The authors also explore the common yet unresolved tension in teaching hospitals for attending physicians who must provide appropriate supervision of trainees while also allowing autonomy for growth. This article is the last of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors. An accompanying editorial (available via the link below) by the series editors reflects on the experiences of producing the 13 articles in this collection, the patient safety movement in general, and the importance of sharing these stories as educational tools to drive improvement.
Fletcher KE, Underwood W, Davis SQ, et al. JAMA. 2005;294:1088.
The authors review the literature on systems changes implemented following the ACGME work hour limits for residents. They found that the research to date does not clearly indicate how such changes have affected residents' education and call for more rigorous study in this area.