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.
“Second victims” are healthcare providers and support staff involved in an unexpected adverse event and experience continuing psychological harm. While some hospitals provide formal support for “second victims,” it is frequently underutilized. In addition to implementing (and improving) formal support programs, this commentary also encourages a culture of safety and understanding of the 6-stage pathway toward recovery.
Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.
Burnout among health care professionals is widely understood as an organizational problem in health care. This study describes a longitudinal, institutional program to reduce burnout and improve provider wellness at an academic medical center. A longstanding crew resource management intervention led to a decreasing number of patient safety events, which the authors connect to culture change. The program also included provision of mindfulness training for trainees and faculty to promote resilience. They measured self-reported burnout at prespecified intervals and documented improvement over time. The authors conclude that the combination of team training and individual mindfulness education can reduce burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed interventions to address burnout among clinicians.
Moffatt-Bruce SD, Huerta T, Gaughan A, et al. Am J Med Qual. 2018;33:420-425.
Collaborating to implement rapid-cycle learning is a strategy to design and sustain patient safety innovations. This commentary describes an AHRQ-funded learning laboratory, the Institute for the Design of Environments Aligned for Patient Safety. The authors outline the infrastructure of the initiative and highlight how its research integrates the results of their activities into system-level improvement.
Moffatt-Bruce SD, Clark S, DiMaio M, et al. Ann Thorac Surg. 2017;105:351-356.
Leadership engagement in patient safety improvement efforts is an important component for success. This commentary highlights the role of clinical, administrative, and board leaders in creating an environment conducive to a culture of safety.
Gray DM, Hefner JL, Nguyen MC, et al. Am J Med Qual. 2017;32:583-590.
The AHRQ Patient Safety Indicators are publicly reported measures of hospital performance. This retrospective study of patient discharges from an academic medical center over a 2-year period found an association between Patient Safety Indicators and longer length of stay, unplanned readmissions, and mortality.
Patterson ES, Sillars DM, Staggers N, et al. Jt Comm J Qual Patient Saf. 2017;43:375-385.
Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Ann Thorac Surg. 2017;103:1693-1699.
Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Surgery. 2016;160:858-868.
The AHRQ Patient Safety Indicators (PSIs) rely on hospital administrative data to screen for patient safety problems. This study used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure) in identifying clinically significant patient safety events and found a positive predictive value of 38.3%. The authors argue that PSI 11 should not be used as a measure for hospital performance.
Hefner JL, Huerta T, McAlearney AS, et al. J Am Med Inform Assoc. 2017;24:310-315.
The AHRQ Patient Safety Indicators (PSIs) represent quality measures derived from administrative data. However, concerns about validity have led to increased scrutiny. This retrospective study analyzed all PSIs identified by standard algorithms over a 1-year period at a single academic medical center. A review team reversed 185 of the 657 PSIs initially identified, citing the two main reasons for reversal to be algorithm limitations and coding misinterpretations. The authors concluded that if PSIs continue to be publicly reported and carry financial implications for hospitals, the quality of administrative data and accuracy of PSI algorithms must be improved.
Moffatt-Bruce SD, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;102:358-62.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.
Hefner JL, Hilligoss B, Knupp A, et al. Am J Med Qual. 2017;32:384-390.
Crew resource management (CRM), a type of team training, is a prime example of an aviation strategy often applied to patient safety. Despite many calls to disseminate CRM throughout health care, data on its effectiveness in improving safety is lacking. This multi-site study examined safety culture, as measured by the AHRQ Hospital Survey on Patient Safety Culture, before and after implementation of CRM in eight departments, across three hospitals. After the training, investigators found a significant, consistent improvement across multiple domains of safety culture, particularly in the areas of teamwork and communication. They propose more widespread implementation of CRM as a strategy to enhance safety culture. A past PSNet interview described the application of CRM to health care.
Rayo MF, Moffatt-Bruce SD. BMJ Qual Saf. 2015;24:282-6.
Alarm fatigue has generated substantial attention as a patient safety hazard. Exploring risks associated with alarm fatigue and factors that contribute to it, this review recommends that interventions and design alternatives be considered to enhance clinician response to alerts.
Hilligoss B, Mansfield JA, Patterson ES, et al. Jt Comm J Qual Patient Saf. 2015;41:134-143.
Handoffs transfer accountability for a patient from one clinician to another. This commentary proposes a framework for transfers from the emergency department to other units within the hospital that highlights environmental, organizational, and social factors that affect these interactions to augment handover quality.
Moffatt-Bruce SD, Denlinger CE, Sade RM. Ann Thorac Surg. 2014;98:396-401.
A general consensus exists that physicians should disclose their own errors, but the responsibility of reporting colleagues' errors to patients and their families is not as clearly understood. This commentary uses a case example to illustrate perspectives for both sides of the debate surrounding the ethics of this issue.
Stawicki P, Cook CH, Anderson HL, et al. Am J Surg. 2014;208:65-72.
In this retrospective analysis, most instances of unintentionally retained foreign objects were due to team errors, highlighting the importance of effective teamwork training. Errors attributed to individual actions accounted for less than 10% of cases.
This meta-analysis identified factors that increase risk of retained foreign objects, including clinical complexity, failure to perform a surgical count, and involvement of multiple surgical teams. These results indicate that multiple prevention efforts are needed to avoid this never event. A past AHRQ WebM&M commentary describes a patient who was discharged with a retained surgical item and reveals technological solutions to reduce risks.
Hilligoss B, Moffatt-Bruce SD. BMJ Qual Saf. 2014;23:528-33.
Communication failures at the time of patient handoffs have been frequently implicated in adverse events. Comparing how narrative modes of communication such as storytelling and structured tools like checklists can be utilized to augment information transfers in health care, this commentary advocates for more research into strategies to improve narrative thinking.