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.
Fleisher LA, Schreiber M, Cardo D, et al. N Engl J Med. 2022;386:609-611.
The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.
Cooper WO, Spain DA, Guillamondegui O, et al. JAMA Surg. 2019;154.
… reports of unprofessional behavior in the 3 years before a surgery were more likely to have patients experience both … behavior so that it can be remediated . Two WebM&M commentaries describe different approaches to addressing …
Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019;130:1039-1048.
Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Lane-Fall MB, Pascual JL, Peifer HG, et al. Ann Surg. 2020;271:484-493.
… Ann Surg … Handoffs represent a vulnerable time for patients in which inadequate … In this prospective cohort study, researchers implemented a handoff protocol designed to improve handoffs between the … Standardization of the handoff process led to a decrease in omitted information and increased the length of …
Lane-Fall MB, Pascual JL, Massa S, et al. Jt Comm J Qual Saf. 2018;44:514-525.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Saf … Standardizing handoffs has been shown to improve … room to intensive care unit as well as the development of a standardized OR-to-ICU handoff protocol. …
Cooper WO, Guillamondegui O, Hines J, et al. JAMA Surg. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Gabriel PE, Volz E, Bergendahl HW, et al. Jt Comm J Qual Patient Saf. 2015;41:160-8.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This study describes the experience of an incident learning program in a radiation oncology department over a nearly 4-year period. Approximately 78% of all staff had …
Speck RM, Foster JJ, Mulhern VA, et al. Jt Comm J Qual Patient Saf. 2014;40:161-167.
Unprofessional behavior can hinder patient safety and create a disruptive work environment for other staff. The Joint Commission requires that organizations have clear processes for detecting and reporting unacceptable behaviors. This commentary describes the development and experience of a Professionalism Committee at the University of Pennsylvania Health System. The committee chair serves as the first point of contact for any behavioral concerns. In this system, the committee chair is a trained psychiatrist, which the authors argue is an important aspect of the program since it allows for early identification of behavioral health issues that could contribute to unprofessionalism. The article includes the specific problems addressed and the referral outcomes of 79 cases over 2 years, along with 3 illustrative case vignettes. A prior AHRQ WebM&M commentary focused on the importance of professionalism in patient safety, and an AHRQ WebM&M perspective reviewed strategies to identify and manage problem behaviors.
Kim MM, Barnato AE, Angus DC, et al. Arch Intern Med. 2010;170:369-76.
Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.