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.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.
Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications.
In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.
Greene MT, Gilmartin HM, Saint S. Am J Infect Control. 2020;48:2-6.
This cross-sectional study reports the results of an ongoing national survey of infection preventionists to assess hospital infection control program characteristics and organizational practices to prevent common healthcare-associated infections. One-third of responding hospitals reported characteristics of organizational safety culture (e.g. employee perceptions of feeling safe to speak up, ask for help, or provide feedback), which was associated with increased odds of using some recommended practices for preventing catheter-associated urinary tract infections and ventilator-associated pneumonia.
Quinn M, Forman J, Harrod M, et al. Diagnosis (Berl). 2019;6:241-248.
Prior research has found that diagnostic errors comprise approximately one-fifth of preventable errors among hospitalized patients. Academic clinical care poses unique risks for diagnostic error because the frontline providers are residents and medical students. Thus, accurate diagnosis relies on robust communication between learners and their supervisors. A team of social scientists and clinicians conducted an ethnographic study of physicians on academic inpatient rounds to identify barriers to timely and correct diagnoses. They found that reliance on one-way communication methods and insufficient face-to-face interactions with patients and consultants hindered effective diagnostic decision-making. Additionally, the electronic health record led to data overload and data fragmentation. The authors offer concrete suggestions for more clinician- and patient-centered technical tools. A WebM&M commentary discussed a diagnostic error involving learners in psychiatry.
This commentary draws parallels between experiences in viewing and exploring meaning in modern art to the challenge of diagnosis. The author discusses how experiences, values, and opinions can affect the interpretation and influence decision-making.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019;28:741-749.
This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.
Health care is working to provide high-value care and prevent overuse while ensuring patient safety. This commentary highlights the importance of educational initiatives, mentors, and use of clinical decision support to help clinicians determine what amount of care is appropriate for a given clinical situation.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28:74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Chopra V, Harrod M, Winter S, et al. J Hosp Med. 2018;13:668-672.
This ethnographic study examined the process of making a diagnosis among academic inpatient medical teams. Investigators observed that diagnosis requires dialogue within team, needed data is often not available, and distractions and time pressure are frequent. These observations may inform future interventions to improve timeliness and accuracy of diagnosis.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27:53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Gupta S, Saint S, Detsky AS. JAMA Intern Med. 2017;177:757-758.
Reliance on information technology has surfaced a myriad of unintended consequences. This commentary highlights the importance of the physician–patient encounter and how such interactions have diminished with the implementation of electronic health records. The authors caution against the downsides of heuristics, cognitive errors, and implicit bias during the initial exam and underscore the value of contextual information gathered from personal interaction.
Mody L, Greene T, Saint S, et al. Infect Control Hosp Epidemiol. 2017;38:287-293.
The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.
Storytelling has been advocated as a strategy to teach and augment awareness in patient safety. In this commentary, the author relates a personal anecdote to illustrate how assumptions can affect clinical reasoning and provides lessons to broaden clinician thinking when working toward determining a diagnosis.
Meddings J, Reichert H, Greene T, et al. BMJ Qual Saf. 2017;26:226-235.
Programs to prevent health care–associated infections (HAIs) have been some of the most prominent successes of the patient safety movement. These programs—including the Keystone ICU program and a recent effort to prevent catheter-associated urinary tract infections—have emphasized improving safety culture along with specific technical interventions. Analyzing data from two AHRQ-funded programs to prevent HAIs, this study sought to examine the relationship between Hospital Survey on Patient Safety Culture scores and HAI rates. Interestingly, no association was found between safety culture scores and HAI rates at the hospital unit level, even though HAI rates consistently improved during the study period. The authors note two possible interpretations of these results: first, safety culture may not be a crucial component of programs to reduce HAIs; second, survey results may not be an accurate measure of safety culture (especially in this study, where survey response rates were low). Other studies have indicated a stronger relationship between safety culture and rates of other types of adverse events. Therefore, despite this study's results, establishing a safety culture remains important.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.