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.
Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.
Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.
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.
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.
McNab D, Bowie P, Ross A, et al. BMJ Qual Saf. 2018;27:308-320.
This systematic review found that pharmacist-led medication reconciliation after hospital discharge reduced medication discrepancies. However, the pooled studies did not demonstrate changes in the readmission rate or emergency department visits following medication reconciliation. The authors suggest further research is needed to determine the effect of medication discrepancies on patient safety.
Vosper H, Hignett S, Bowie P. Med Teach. 2017;40:357-363.
Human factors engineering helps improve human performance and reduce the risks associated with user error. This commentary discusses the current integration of human factors engineering theories and methods into education and training. The authors outline tactics to help educators translate human factors engineering concepts into their programs such as building on what works well.
Price J, Man SL, Bartlett S, et al. J Eval Clin Pract. 2017;23:779-796.
Systems thinking enables organization-wide efforts to enhance patient safety. Investigators employed a systems approach to reduce risks associated with repeated medication prescribing in 48 primary care practices in the National Health Service. The authors describe the main themes of the more than 750 improvement ideas generated.
Grant S, Checkland K, Bowie P, et al. Implement Sci. 2017;12:56.
Test result management is a critical aspect of ambulatory patient safety. This direct observation study identified highly variable strategies across outpatient practices with different vulnerabilities. These results underscore the need to develop interventions to enhance management of test results.
Pickup L, Lang A, Atkinson S, et al. Ergonomics. 2018;61:15-25.
Applying human factors engineering to design improvements can enhance safety in the complex health care environment. This commentary uses case examples to illustrate how combining human factors engineering and the systems approach can help improve safety of primary care and blood sampling.
de Wet C, Black C, Luty S, et al. BMJ Qual Saf. 2017;26:335-342.
The trigger tool approach, in which a prespecified value triggers medical record review to identify patient safety issues, is a method to detect adverse events. This study offered incentives to conduct and report results of trigger reviews in primary care. Practices successfully implemented and reported results from trigger reviews, suggesting that trigger reviews are a feasible strategy to enhance outpatient safety.
Hignett S, Lang A, Pickup L, et al. Ergonomics. 2018;61:5-14.
Barriers to achieving safe, high-quality health care are well known. This study described the myriad challenges faced by the National Health Service (NHS) in its quest to provide optimal patient care. The authors suggest that the NHS lags behind other safety critical industries in applying human factors principles.
McNab D, Bowie P, Ross A, et al. Educ Prim Care. 2016;27:258-66.
Error investigation in health care settings varies widely. The authors of this conceptual paper suggest that a systems approach will lead to a reduction in vulnerabilities and support a positive safety culture. They argue that human error should be the starting point rather than a root cause in any error analysis.
Hignett S, Otter ME, Keen C. Int J Nurs Stud. 2016;59:1-14.
Adverse events are thought to be common in patients receiving home health care. This systematic review defined home care safety risks for both patients and caregivers, including awkward working positions, social distractions, abuse and violence, and other issues that are relatively unique to this care setting.
Bowie P, Halley L, Blamey A, et al. BMJ Open. 2016;6:e009526.
Patient safety interventions in ambulatory practice remain rare. In this evaluation of a pilot program, the study team interviewed general practice physicians, nurses, and practice managers who participated in the program. Participants believed teamwork and safety culture had improved, but they described challenges to implementing the pilot as planned.
Bowie P, Price J, Hepworth N, et al. BMJ Open. 2015;5:e008968.
This retrospective study of abnormal laboratory test orders and results in primary care uncovered multiple vulnerabilities, similar to prior studies. The authors describe a conceptual model to comprehensively address the safety of laboratory testing and results management in primary care, a useful step for future interventions.
Hignett S, Jones EL, Miller D, et al. BMJ Qual Saf. 2015;24:250-254.
Human factors engineering and quality improvement each offer promising strategies for designing patient safety interventions. This commentary discusses the value of cross-training individuals in elements of both disciplines to encourage integrated research, education, and professional development opportunities.
Ahmed M, Arora S, McKay J, et al. BMC Fam Pract. 2014;15:206.
There is a consensus that training in patient safety must be integrated into medical education, but less agreement on the core skills that students should be taught. A prior study used a consensus approach to identify the key attributes of a safe practitioner. In this study, a group of educational supervisors of primary care trainees in the United Kingdom were surveyed regarding how they perceived the importance of each of these skills. Clinicians identified many nontechnical skills as being essential for safe practice, including conscientiousness and situational awareness, and agreed that these abilities could be taught through formal curricula. The concepts explored in this study have been used to develop a patient safety curriculum that is being implemented widely in the United Kingdom.
Bowie P, Halley L, McKay J. BMJ Open. 2014;4:e004245.
In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.
Hignett S, Carayon P, Buckle P, et al. Ergonomics. 2013;56:1491-503.
This commentary highlights challenges and potential risks around implementing human factors engineering approaches to improve patient safety and recommends areas of research to advance the understanding and reliability of these concepts.