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.
… Medicine University of California, San Francisco … Robert M. Wachter, MD … Professor and Chair, Department of Medicine … Chair University of California, San Francisco … Sumant … Robert … Ranji … Wachter … R … Sumant R Ranji … RobertWachter …
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
… and—probably most importantly—making the economics work. … Robert M. Wachter, MD … Professor and Chair, Department of Medicine … New York Times Magazine. May 16, 2018. [Available at] … Robert … Wachter … RobertWachter … Editor's note … : Dr. …
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.
Sarkar U, McDonald KM, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.
Patient safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the methods and results of an AHRQ Technical Brief, this commentary summarizes expert opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors outline patient safety practices relevant to the ambulatory setting and suggest activities to advance improvement efforts in outpatient care, such as measure development and use of health information technologies.
… competency—be addressed in equally innovative ways. … Robert M. Wachter, MD … Professor and Chair, Department of Medicine … best. New Yorker. October 3, 2011. [Available at] … Robert … Wachter … RobertWachter … Editor's note: … Dr. …
This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Gupta R, Moriates C, Harrison JD, et al. BMJ Qual Saf. 2017;26:475-483.
Health care institutions are increasingly focused on providing high-value care and preventing overuse. In this study, researchers developed a validated High-Value Care Culture Survey and found that administering the survey at two large academic medical centers provided health care leaders with an opportunity to target their improvement efforts.
Pannick S, Wachter R, Vincent CA, et al. BMJ. 2016;355:i5417.
Patient safety research and commentary often focus on specialized care processes rather than medical wards. Exploring challenges to improving safety in the medical ward environment, this commentary outlines four strategies to address complexity of implementing initiatives in this setting.
Gupta K, Wachter R, Kachalia A. BMJ Qual Saf. 2017;26:164-168.
Although financial incentives have been widely adopted, they may not lead to organizational improvements. This commentary raises concerns about including hospital mortality in incentive programs, since patient deaths do not necessarily mean poor quality care. The authors suggest that further research is needed to enhance accuracy of risk-adjusted mortality and to account for differences in patient treatment preferences.
Young JQ, Wachter R, Cate OT, et al. BMJ Qual Saf. 2016;25:66-70.
Implementing standardized handoff processes has garnered attention as a strategy to improve patient safety. In this commentary, the authors apply cognitive load theory to handoff tasks to demonstrate how to improve handover bundles and enhance reliability.
Pannick S, Davis R, Ashrafian H, et al. JAMA Intern Med. 2015;175:1288-98.
Interdisciplinary team care interventions are increasingly common on medical wards, based partly on a widespread belief that these practices will improve efficiency and patient safety. This systematic review sought to evaluate the performance of hospital-based interdisciplinary teams on patient outcomes. The majority of studies have chosen length of stay, complications, readmission, or mortality rates as their primary outcomes, but interdisciplinary teams rarely seem to affect these traditional quality measures, which may be insensitive to teamwork improvements in care delivery. The authors call for establishing more relevant outcomes to evaluate interdisciplinary team interventions. An accompanying commentary notes that this systematic review provides an opportunity to highlight the potential harms of choosing the wrong metrics to evaluate an intervention, which can undermine a program's mission.
Austin M, Jha AK, Romano PS, et al. Health Aff (Millwood). 2015;34:423-430.
One strategy to improve patient safety is public reporting of performance data, and hospital quality ratings have proliferated. In this study, researchers examined the extent of agreement among hospital ratings issued by U.S. News & World Report, HealthGrades, The Leapfrog Group, and Consumer Reports. Each rating system has a different emphasis, varying inclusion and exclusion criteria, and focuses on different measures of quality. There is very little agreement among the ratings for either high or low performance—not one hospital was rated as a top performer across all four ratings—which makes these ratings challenging for consumers to interpret or use in decision making. These findings are consistent with prior work demonstrating variability in surgical quality rankings. The authors call for transparency in how ratings are constructed and clear communication with consumers to facilitate informed decisions regarding their care. A recent AHRQ WebM&M interview with Leah Binder, President and CEO of The Leapfrog Group, explored the development of the Hospital Safety Score and Leapfrog Hospital Survey.
Pannick S, Beveridge I, Wachter R, et al. Eur J Intern Med. 2014;25:874-87.
This narrative review of safety efforts on general hospital wards found that most interventions encompass one or more of five areas: staffing levels, interprofessional collaboration, standardization of care such as use of checklists, rapid response to clinical deterioration, and safety culture. The authors advocate for increasing the evidence base in all of these areas, as gaps in implementation and sustainment are prevalent.
… systems-based approach to patient safety. … Christopher … Robert … Moriates … Wachter … Christopher Moriates … RobertWachter …
While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.
McTiernan P, Wachter R, Meyer GS, et al. BMJ Qual Saf. 2015;24:162-6.
Past commentaries have explored the tension between balancing no blame and individual accountability for medical errors. This commentary summarizes a debate exploring accountability in patient safety, with one argument describing the need for health care to differentiate individual failures from systems problems and an opposing perspective suggesting that incorporating blame would hinder progress in patient safety.
Ranji SR, Rennke S, Wachter R. BMJ Qual Saf. 2014;23:773-80.
This narrative review found that while computerized provider order entry combined with clinical decision support systems effectively prevented medication prescribing errors, there was no clear effect on clinical adverse drug event rates. This finding may be due to alert fatigue and other unintended consequences of the technology.
Efforts to improve patient safety were initially built on the establishment of a no-blame philosophy, but recently experts have called for a just culture that balances systems-based thinking with personal accountability. This study surveyed physicians, nurses, medical students, and inpatients regarding attitudes toward public reporting and penalties for violations of basic safety protocols. The authors used scenarios involving hand hygiene, fall risk assessment, and preoperative time-outs since they are backed by strong evidence, easy to perform, and linked to important and common patient harms. Respondents endorsed feedback and penalties for clinicians that failed to follow these evidence-based practices. Health care professionals tended to favor punitive measures such as fines, suspensions, and firing, over public reporting. This may provide some insight into the power of public reporting to motivate change. An AHRQ WebM&M perspective discusses the organizational implementation of a just culture.
Austin M, D'Andrea G, Birkmeyer JD, et al. J Patient Saf. 2014;10:64-71.
Despite availability of multiple publicly reported patient safety accountability measures, a composite score for hospital safety has yet to be developed. The Leapfrog Group convened a panel of experts to develop such a score for hospitals in the United States. The group synthesized 26 distinct safety indicators into a score comprised equally of process measures (e.g., barcode medication ordering), which recognize safety efforts, and outcome measures (e.g., catheter-associated infections). The panel also weighted the metrics based on the strength of evidence, the opportunity for improvement (i.e., the variation in performance), and the impact (i.e., the potential number of patients affected). After calculating the score for all US hospitals for which data were available, they found lower scores for rural, publicly owned hospitals with a higher percentage of patients with Medicaid as their insurance.