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.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;25:3215-3224.
Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.
Joseph K, Newman B, Manias E, et al. Patient Educ Couns. 2022;105:2778-2784.
Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.
Newman B, Joseph K, Chauhan A, et al. Health Expect. 2021;24:1905-1923.
Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).
Busch IM, Moretti F, Campagna I, et al. Int J Environ Res Public Health. 2021;18:5080.
Clinicians involved in unexpected patient outcomes can experience negative emotions and frequently need access to second victim support programs. This systematic review describing 12 second victim support programs identifies staff benefits, implementation challenges, and experiences of peer supporters. Affected staff and peer supporters reported the benefits of the programs. Challenges included blame culture, limited awareness of program existence, and lack of financial resources. Findings indicate a need for implementing new second victim support programs, promoting current programs, and monitoring peer supporters’ well-being.
Connors C, Dukhanin V, Norvell M, et al. J Healthc Manag. 2021;66:19-32.
The Resilience in Stressful Events (RISE) program provides peer support for healthcare workers who are involved in an adverse event. RISE program volunteers surveyed in this study reported positive perceptions of program participation and personal empowerment.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
Bhasin S, Gill TM, Reuben DB, et al. N Engl J Med. 2020;383:129-140.
This study randomized primary care practices across ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury, which included risk assessment and individualized plans administered by specially trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care.
Chauhan A, Walton M, Manias E, et al. Int J Equity Health. 2020;19:118.
In this systematic review, the authors characterized patient safety events affecting ethnic minority populations internationally. Findings indicate that ethnic minority populations experience higher rates of hospital-acquired infections, complications, adverse drug events, and dosing errors. The authors identified several factors contributing to the increased risk, including language proficiency, beliefs about illness and treatment, interpreter use, consumer engagement, and interactions with health professionals.
Busch IM, Saxena A, Wu AW. J Patient Saf. 2021;17:358-362.
In this literature review, the authors identified patient-, clinician-, and institutional-level barriers to patient involvement in patient safety investigations. Potential strategies for overcoming barriers are also discussed, such as adopting a blame-free climate and enhancing clinician training in error disclosure and communication.
Wu AW, Connors C, Everly GS. Ann Intern Med. 2020;172:822-823.
To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic:
Encourage leadership to focus on resilience
Ensure that crisis communication provides both information and empowerment
Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.