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.
Black GB, Lyratzopoulos G, Vincent CA, et al. BMJ. 2023;380:e071225.
Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.
Wade C, Malhotra AM, McGuire P, et al. BMJ. 2022;376:e067090.
The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.
Amalberti R, Staines A, Vincent CA. Int J Qual Health Care. 2022;34:mzac006.
Leadership engagement is key to achieving patient safety goals. When it comes to improvement and innovation, healthcare organizations must balance multiple, sometimes conflicting, aims, such as cost, clinician wellbeing, and patient safety. This commentary outlines how healthcare organizations can manage multiple complex aims in relation to improvement and innovation projects. Four principles of managing multiple aims and five key strategies for practical action are described.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … active, independent practice . The authors discuss how a systemic approach is required to situate these … to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July effect. J …
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child. 2021;106:333-337.
In the second of a two-part series, using examples from newborn units, the authors present a framework for supporting practitioners in low-resource settings to improve patient safety across four areas: (1) prioritizing critical processes, (2) improving the organization of care, (3) control of risks, and (4) enhancing responses to hazardous situations.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106:326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the Systems Engineering Initiative for Patient Safety (SEIPS) framework to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. BMC Med. 2020;18:340.
Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
Wu AW, Buckle P, Haut ER, et al. J Patient Saf Risk Manag. 2020;25:93-96.
This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
… J Qual Health Care … The authors of this editorial propose a five-step strategy for patient safety and quality … the learning system to develop resilience . … Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety …
Amelung D, Whitaker KL, Lennard D, et al. BMJ Qual Saf. 2019;29:198-208.
… did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment … testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer. …
Amalberti R, Vincent CA. BMJ Qual Saf. 2020;29:60-63.
… BMJ Qual Saf … BMJ Qual Saf … Health care is considered a high-risk industry due to clinical, administrative, … economic, and regulatory stressors. This review explores a range of approaches to managing the safety of patients in …
Higham H, Greig PR, Rutherford J, et al. BMJ Qual Saf. 2019;28:672-686.
Nontechnical skills, such as teamwork and communication, are critical to safe care delivery, but can be difficult to measure. This systematic review examined validated approaches for assessing nontechnical skills using direct observation. Researchers analyzed 118 articles that discussed 76 unique tools for measuring nontechnical skills. This wide range of instruments assessed individuals or teams in various health care settings, either in simulation or actual clinical practice. They identified substantial variability in how these approaches were validated and whether individual studies reported the usability of each tool. The authors spotlight the need for standardization in how to develop, test, and implement assessments of nontechnical skills. A related editorial discusses the findings of this systematic review in the context of previous research and advocates for future work to standardize assessment of nontechnical skills in health care.
Cecil E, Bottle A, Esmail A, et al. BMJ Qual Saf. 2018;27:965-973.
… by the Imperial College Mortality Surveillance System (a national hospital mortality surveillance system that … trusts. On average, mortality risk decreased after a trust received a mortality alert. However, the authors conclude that random …