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.
Averill P, Vincent CA, Reen G, et al. Health Expect. 2023;26:51-63.
Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Barrow E, Lear RA, Morbi A, et al. BMJ Qual Saf. 2023;32:383-393.
Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.
Pring ET, Malietzis G, Kendall SWH, et al. Int J Surg. 2021;91:105987.
This literature review summarizes approaches to crisis management used by non-healthcare institutions (e.g., private businesses, large military organizations) in response to the COVID-19 pandemic and how healthcare organizations – particularly the surgical community – can leverage these approaches in operational planning and crisis management.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care. In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.
Wæhle HV, Haugen AS, Wiig S, et al. BMC Health Serv Res. 2020;20.
This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies. Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.
Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
Archer S, Thibaut BI, Dewa LH, et al. J Psychiatr Ment Health Nurs. 2019;27:211-223.
Researchers conducted focus groups in this qualitative study of staff in mental healthcare settings and assessed the barriers and facilitators to incident reporting. The authors identified unique challenges to incident reporting in mental health, including the incidence of violence and aggressive behavior. Participants often underreported violent or aggressive events because they attributed the behavior to the patient’s diagnosis, and cited dissatisfaction with how reported incidents were handled by police.
Haugen AS, Sevdalis N, Søfteland E. Anesthesiology. 2019;131:420-425.
Checklists have been widely embedded into care processes, despite questions regarding their effectiveness in improving safety. This review summarizes the evidence on use of the WHO surgical checklist and highlights the need for persistence, long-term commitment, and implementation strategy to prevent complications.
Edbrooke-Childs J, Hayes J, Sharples E, et al. BMJ Qual Saf. 2018;27:365-372.
Huddles are frequently used in health care to enhance situational awareness. This study describes the development of an observation tool designed to evaluate the effectiveness of team huddles in the inpatient setting.
Weaknesses in error reporting include lack of use, data quality, and reliable feedback. This review describes a framework to better understand the challenges affecting reporting successes. The authors suggest that focusing on organizational, process, and system issues is necessary to design interventions that enhance practitioner use of reporting mechanisms.
Pannick S, Athanasiou T, Long SJ, et al. BMJ Open. 2017;7:e014333.
This prospective trial with concurrent controls examined whether frontline team safety surveillance reduced the instances of longer-than-average length of stay for a given diagnosis. The study team found that incomplete implementation of the intervention actually increased length of stay, whereas stringent implementation of the intervention improved length of stay. The authors conclude that suboptimal implementation can negatively affect safety.
Parand A, Faiella G, Franklin BD, et al. Ergonomics. 2018;61:104-121.
Informal caregivers can make errors in administering medications to patients in home settings. This human factors analysis identified multiple vulnerabilities, including incorrect dosing, storage, timing, and failure to discontinue medications as instructed. The authors note an overall lack of support and communication for caregiver-administered medications in home and community settings.
Frontline providers possess unique insights for improving patient safety and their perceptions may be different from those of managers and clinical leaders. In this qualitative study, researchers sought to harness this expertise and perspective through a multifaceted intervention that involved structured multidisciplinary briefings, increased organizational awareness of challenges identified by frontline providers, and feedback—referred to as prospective clinical team surveillance. They found that the prospective safety intervention created a sense of psychological safety in which team members were more likely to raise concerns without fear of punishment and increased frontline provider engagement in improvement opportunities. The authors emphasize that such an approach provides managers with better insights into issues affecting care delivery. A past PSNet perspective discussed workarounds and resiliency on the front lines of health care.
Howell A-M, Burns EM, Hull L, et al. BMJ Qual Saf. 2017;26:150-163.
Although incident reporting systems remain central to most patient safety programs, they are frequently criticized for their inability to accurately measure harm events and near misses. Researchers interviewed experts to establish consensus on the role of patient safety incident reporting systems. Using a Delphi approach, they were able to derive 40 recommendations. Consistent with prior research, experts agreed that incident reporting systems should not be used to measure rates of harm.
Hull L, Athanasiou T, Russ S. Ann Surg. 2017;265:1104-1112.
Implementation science is utilized to understand how to apply research into practice. This review explores the use of implementation science in surgical patient safety initiatives to enable the translation of research into active care. The authors focus their discussion on the widely implemented World Health Organization surgical checklist to identify factors that drive and sustain improvement, including context, implementation strategies, and outcomes.
Macdonald AL, Sevdalis N. J Pediatr Surg. 2017;52:504-511.
This systematic review evaluated the patient safety evidence associated with pediatric surgery. Although investigators found sound evidence to support the use of handoff tools, they suggest that further research on interventions to improve safety in pediatric surgery is needed.
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.