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.
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.
Morris RL, Giles SJ, Campbell S. Health Expect. 2023;Jan 16.
Patient and caregiver engagement is an important strategy for improving the quality and safety of care. This qualitative study with 18 patients and/or caregivers explored perspectives on engagement in primary care. While participants were supportive of engagement in their care and safety, some expressed concerns regarding additional workload for patients. Participants also provided feedback on a patient safety guide for primary care (PSG-PC) and identified areas to embed the PSG-PC into routine interactions with primary care, particularly for individuals caring for a family member with complex or chronic health conditions.
Hodkinson A, Zhou, A, Johnson J, et al. BMJ. 2022;378:e070442.
Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;30:977-985.
Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.
Hodkinson A, Tyler N, Ashcroft DM, et al. BMC Med. 2020;18:313.
Medication errors represent a significant source of preventable harm. This large meta-analysis, including 81 studies, found that approximately 1 in 30 patients is exposed to preventable medication harm, and more than one-quarter of this harm is considered severe or life-threatening. Preventable medication harm occurred most frequently during medication prescribing and monitoring. The highest rates of preventable medication harm were seen in elderly patient care settings, intensive care, highly specialized or surgical care, and emergency medicine.
Williams R, Jenkins DA, Ashcroft DM, et al. The Lancet Pub Health. 2020;5:e543-e550.
The COVID-19 pandemic has led to patients delaying or forgoing necessary health care, which can contribute to diagnostic and treatment delays. This retrospective cohort study used primary care data to investigate the indirect effect of the COVID-19 pandemic on primary care health care use and subsequent diagnoses among residents in a poor, urban area in the United Kingdom. Between March and May 2020, there was a 50% reduction in expected diagnoses for mental health conditions, as well as substantial decreases in diagnoses and associated medication prescriptions for circulatory system diseases and type 2 diabetes.
This feasibility study surveyed 1,750 patients using the primary care patient measure of safety (PC PMOS) tool to obtain patient feedback about the safety of their care in primary care settings. Findings indicate that this approach complements existing safety improvement activities, can be integrated into existing feedback service requirements, and should be explored further by larger effectiveness trials.
Stocks SJ, Alam R, Bowie P, et al. J Patient Saf. 2019;15:334-342.
"Never events" are serious but generally preventable patient safety incidents. This study surveyed general practitioners in the UK to assess the incidence of specific never-events in those practices, and whether practitioners agreed with the specific events being designated as a never-event. The most commonly reported events were not investigating abnormal test results (45% of practices) and prescribing despite documented adverse reactions (65% of practices); however, these events were also less likely to be designated "never events" by respondents.
Carson-Stevens A, Campbell S, Bell BG, et al. BMC Fam Pract. 2019;20:134.
Most patient safety research has focused on tertiary care or specialty care settings, but less is known about safety in primary care settings and there is no clear definition of patient safety incidents and harm occurring in these settings. The authors convened a panel of family physicians and used a consensus method to define “avoidable harm” within family practice. Most scenarios found to be avoidable and included in the proposed definition involved failure to adhere to evidence-based practice guidelines, lack of timely intervention, or failure in administrative processes, such as referrals or procedures for following up on results.
Panagioti M, Khan K, Keers RN, et al. BMJ. 2019;366:l4185.
The extent of harm due to patient safety problems varies across studies. This systematic review sought to estimate the prevalence of preventable harm in medical care overall. Researchers synthesized data from 70 studies and estimated that 6% of patients receiving medical care experience preventable harm. Harm related to medications, diagnosis, health care–associated infections, and procedures accounted for significant proportions of preventable harm. The authors conclude that focusing on evidenced-based strategies to address preventable patient harm would improve health care quality and subsequently reduce costs. A related editorial calls for improving measurement of preventable harm. Another editorial spotlights the importance of understanding the causes of preventable harm in health care.
Giles SJ, Parveen S, Hernan AL. BMJ Qual Saf. 2019;28:389-396.
This measure validation study examined the reliability and validity of a patient-reported measure of safety in primary care. The analysis established concurrent validity and reliability, paving the way for measuring patients' perceptions of ambulatory safety.
Medically complex patients experience more safety hazards than their healthier peers. This ethnographic study described the safety experience of 26 medically complex British adults. Physicians and patients alike struggled to achieve a balance between underinvestigating health concerns and risking diagnostic delays and overinvestigating health concerns and exposing patients to unnecessary testing.
Stocks SJ, Donnelly A, Esmail A, et al. BMJ Open. 2018;8:e020952.
Adverse events reported by patients are often different and more expansive than safety hazards identified by health care providers. Researchers elicited adverse events from a nationally representative sample of British outpatients. About 8% of patients reported an adverse event, which were frequently problems with medications, accessing care in a timely way, and diagnostic errors.
Litchfield I, Gill P, Avery T, et al. BMC Fam Pract. 2018;19:72.
Researchers implemented a multicomponent patient safety toolkit designed to help outpatient practices in England provide safer care. They subsequently interviewed staff to better understand their perspective regarding the toolkit's value as well as barriers to its use.
Hays R, Daker-White G, Esmail A, et al. BMC Health Serv Res. 2017;17:754.
Patient safety in ambulatory care is receiving increased attention. In this qualitative study, researchers interviewed 26 patients over the age of 65 with multiple comorbid medical conditions to better understand perceived threats to patient safety in primary care among this population.
Alam R, Cheraghi-Sohi S, Panagioti M, et al. BMC Fam Pract. 2017;18:79.
A recent commentary described fear of uncertainty as a contributor to diagnostic error. This systematic review developed a framework for how primary care clinicians manage uncertainty, consisting of cognitive, emotional, and ethical domains. However, the review identified little data on best ways to support clinicians in handling uncertainty.