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The PSNet Collection: All Content

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.

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Displaying 1 - 20 of 30 Results
Wong BM, Coffey M, Nousiainen MT, et al. J Grad Med Educ. 2017;9:66-72.
Error disclosure is universally recommended but incompletely implemented. Comparing disclosure skills among residents who completed experiential training to a historical cohort, this study found that current residents performed better. These results indicate that safety culture with respect to disclosure may be improving over time.
Levinson W, Yeung J, Ginsburg S. JAMA. 2016;316:764-5.
Disclosing medical errors to patients is essential for maintaining a therapeutic relationship and preventing further harm. This commentary describes a case in which a physician inadvertently used nonsterile instruments to perform procedures on two patients and presents options for what the physician might do next. Recommended best practices for error disclosure include being honest about what happened, explicitly stating that an error occurred, and explaining to the patient any relevant specific information that might be helpful in terms of necessary follow-up. The authors suggest that all errors be formally reviewed to prevent future harm and that health care systems should create an environment that facilitates error reporting.
Staiger TO, Mills LM, Wong BM, et al. Am J Med. 2016;129:540-6.
A survey of academic medicine departments sought to identify quality improvement and patient safety activities in written promotion criteria. Investigators suggest language to use in promotion criteria that acknowledges quality and safety activities as core to clinical excellence, includes quality and safety as areas of scholarship, and delineates how the impact of these activities should be evaluated. The authors recommend that academic medical centers adopt such criteria across more institutions.
Wu AW, McCay L, Levinson W, et al. J Patient Saf. 2017;13:43-49.
Based on a series of international expert meetings, this qualitative analysis identified key challenges in error disclosure: policy implementation, patient expectations, confidentiality and legal privilege, aligning disclosure with liability, and documenting and tracking disclosure. These barriers suggest that multiple actions are needed to bolster disclosure efforts. The authors advocate for collaboration between health systems and policymakers, enhanced patient and provider education to foster a blame-free safety culture, and establishment of standard metrics to document and benchmark disclosure across institutions. In a past AHRQ WebM&M perspective, Dr. Albert Wu discussed the importance of disclosing adverse events.
Gallagher TH, Mello MM, Levinson W, et al. N Engl J Med. 2013;369:1752-7.
Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.
Stroud L, Wong BM, Hollenberg E, et al. Acad Med. 2013;88:884-92.
When an error has occurred, many physicians choose their words carefully—failing to explicitly describe the error, acknowledge responsibility, or express sympathy to patients. This in part occurs because training in error disclosure is not a standard component of medical school or residency curricula. This review found that when implemented, error disclosure training generally resulted in improved knowledge and self-reported comfort with the disclosure process. However, few studies assessed whether training led to real-world behavior change. A difficult case of error disclosure is discussed in an AHRQ WebM&M commentary.
Wong BM, Etchells E, Kuper A, et al. Acad Med. 2010;85:1425-39.
A recent report by the National Patient Safety Foundation called for medical schools and residency programs to reengineer their curricula to emphasize patient safety and quality improvement (QI) concepts. This systematic review evaluated the published literature on existing safety and QI curricula, and found that curricula were generally popular among trainees and resulted in increased knowledge of safety or QI concepts. Curricula focused on teaching systems analysis and continuous quality improvement principles, and some studies did find improvement in care processes associated with the educational intervention.
Loren DJ, Garbutt J, Dunagan C, et al. Jt Comm J Qual Patient Saf. 2010;36:101-8.
Patients desire and deserve disclosure of any errors that occur in their care, but fear of malpractice lawsuits is one of many factors that contribute to clinicians failing to disclose errors in a timely and transparent fashion. This survey compared how risk management professionals and physicians responded to simulated error scenarios. The researchers found that while risk managers were more likely to recommend full disclosure of both serious and less serious errors, physicians were more likely to offer an apology to the patient. Apologies may in fact be used as evidence in a malpractice lawsuit under certain circumstances—a 2008 review of "apology laws" found that while "expressions of sympathy" are generally protected from use as evidence, "admissions of fault" are admissible, even when such admissions include an apology. This fact may have influenced the risk managers' advice against apologizing. The tense relationship between error disclosure and malpractice liability is discussed in a PSNet perspective.
Garbutt J, Waterman AD, Kapp JM, et al. Health Aff (Millwood). 2008;27:246-255.
This AHRQ-funded study surveyed more than 1000 physicians to understand their beliefs about error reporting and their use of current reporting systems. More than half the respondents reported involvement in a serious error with a similar proportion agreeing that system failures, rather than individual ones, are the cause. Most physicians did describe the use of formal reporting systems but felt they were largely inadequate mechanisms to both communicate and prevent errors. The authors conclude that physicians are in fact engaged in discussing errors but that current systems promote communicating these events through avenues that may not capture them at an institutional level, such as reporting them to a colleague. A past AHRQ WebM&M perspective discussed the experiences and success of the Minnesota adverse health events reporting system.