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.
Balestracci B, La Regina M, Di Sessa D, et al. Intern Emerg Med. 2023;18:275-296.
The COVID-19 pandemic extended face-masking requirements from healthcare providers to the general public and patients. This review summarizes the challenges mask wearing poses to the general public. Challenges include discomfort, communication issues, especially for people with hearing loss, and skin irritation. Despite these issues, the authors state the benefits outweigh the risks of masks and appropriate education may improve mask use.
Fitzsimons J. Int J Qual Health Care. 2021;33:mzaa051.
This article discusses the importance of leveraging quality improvement and patient safety science in acute and emergency situations. Methods and tools such as rapid learning cycles, huddles, team-based approaches, and debriefing and their applications to the COVID-19 pandemic are discussed.
Trivedi A, Sharma S, Ajitsaria R, et al. Arch Dis Child Educ Pract Ed. 2019;105:122-126.
Medication reconciliation to ensure accuracy of patient medication lists has been difficult to implement. This project report describes an initiative to enhance the timeliness of medication reconciliation for pediatric inpatients. Use of Plan-Do-Study-Act cycles helped inform the evolution of the work. The authors emphasize the importance of engaging the entire care team as well as patients and families to enable completion of the process.
Cheung R, Roland D, Lachman P. Arch Dis Child. 2019;104:1130-1133.
Children are vulnerable to delayed or missed diagnosis, infections, and medication errors. This commentary summarizes the current state of pediatric patient safety improvement efforts in the United Kingdom and emphasizes the importance of systems approaches to safety. The authors highlight huddles and pediatric early warning systems as two tactics that improve the reliability of communication to address the complex needs of pediatric patients.
Ward ME, De Brún A, Beirne D, et al. Int J Environ Res Public Health. 2018;15:E1182.
Change initiatives require broad-based collective design strategies to ensure the range of needs are addressed. This commentary explains how one hospital group used codesign methods to engage leadership in a teamwork and culture improvement project. The authors describe specific tools and tactics used to implement the work and summarize the value of the approach for other health care organizations.
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.
Lachman P, Nicklin W. Healthc Manage Forum. 2017;30:233-236.
Hospital boards and executives can help drive safety improvement. This commentary suggests that organizational leadership should engage staff and peers in creating the culture change needed to launch and sustain advances in patient safety.
Lambert V, Matthews A, MacDonell R, et al. BMJ Open. 2017;7:e014497.
This systematic review found that rapid response systems or teams are widely used, but comprehensive evaluation of these systems is lacking. The authors call for a sociotechnical evaluation of this complex intervention in order to truly characterize its impact on safety.
Lachman P, Linkson L, Evans T, et al. BMJ Qual Saf. 2015;24:337-44.
Through an iterative process, researchers developed and tested a simple tool for patients and family members to report potential harms during hospitalization. The tool led to some improvements in staff reporting and other safety behaviors, but there was no measurable change in safety culture scores for the ward during the study period. This tool is an example of the increasingly utilized strategy of engaging patients in preventing errors.
Change management has been promoted as a strategy to implement improvements in clinical settings. This commentary discusses the complexity around introducing change in health care and suggests that change management, systems thinking, and employee engagement are elements of successful quality improvement initiatives.
Woodhead T, Lachman P, Mountford J, et al. BMJ Qual Saf. 2014;23:619-23.
The Francis report is a seminal publication that calls for improvement of health care delivery in the National Health Service. This commentary describes initiatives that promote enhancing workforce involvement in developing understanding and skills backed by leadership and policy to achieve sustainable improvements.