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.
Cho H, Steege LM, Arsenault Knudsen ÉN. Res Nurs Health. 2023;46:445-453.
Psychological safety, the feeling of confidence that speaking up will not result in punishment or shame, can have a positive impact on both patient and healthcare worker outcomes. Conducted in 2021, this study involved 867 hospital nurses in the United States. Nurses with higher psychological safety were more satisfied with their jobs, less likely to leave in the next year, and reported higher patient safety ratings.
Mattsson TO, Lipczak H, Pottegård A. Qual Manag Health Care. 2019;28:33-38.
This study employed failure mode and effect analysis to detect risks in oral chemotherapy regimens. Researchers included both provider and patient perspectives and found that the two groups identified distinct risks, with patient engagement providing unique information about the home setting.
Chen Q, Larochelle MR, Weaver DT, et al. JAMA Netw Open. 2019;2:e187621.
Reducing opioid-related harm is a major patient safety priority. This simulation study used a mathematical model to predict the effect of existing opioid misuse interventions on opioid overdose mortality. The researchers compared the expected decline based on the current trend over time versus the effect of a 50% faster reduction in misuse. Their calculations suggest that interventions such as prescription drug monitoring programs and insurance coverage changes will result in only a small absolute decrease in opioid overdose deaths. The authors call for developing and testing other strategies for opioid safety. An Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to address opioid misuse.
Christiansen AH, Lipczak H, Knudsen JL, et al. Cancer Epidemiol. 2017;49:38-45.
In this study, researchers surveyed a sample of cancer patients in Denmark to understand perceived errors in follow-up care. About a third of respondents identified one or more errors during follow-up. The authors suggest that improving test result management, care coordination, and medical records may help mitigate such errors.
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Mattsson TO, Holm B, Michelsen H, et al. Ann Oncol. 2015;26:981-6.
This prospective study found that computerized provider order entry (CPOE) did not reduce the overall incidence of chemotherapy prescribing errors, a high-risk clinical area. Compared with paper orders, CPOE decreased calculation errors but introduced other errors. This study affirms that CPOE alone cannot address medication safety.
Mattsson TO, Knudsen JL, Lauritsen J, et al. BMJ Qual Saf. 2013;22:571-9.
The Institute for Healthcare Improvement's Global Trigger Tool is being widely implemented as a means of identifying safety hazards through focused chart review. However, this Danish study calls its utility into question, as the investigators found poor interrater reliability when using the tool to identify adverse events in an oncology hospital. As a result, it was not possible to track error rates over time. Other commentators have recommended that hospitals use multiple complementary methods to detect safety problems, and this approach was recently endorsed in the AHRQ Making Health Care Safer II report.
Lipczak H, Knudsen JL, Nissen A. BMJ Qual Saf. 2011;20:1052-6.
A comprehensive view of patient safety hazards requires identifying safety issues through multiple data sources. This Danish study analyzed safety problems in oncology care through voluntary error reports, retrospective chart review using the Global Trigger Tool, and patient reports. While each data source revealed unique hazards, common problems in this patient population included treatment-related harm (from chemotherapy and other procedures), health care–associated infections, and problems related to communication between providers. An AHRQ WebM&M commentary discusses a preventable complication in a patient receiving outpatient chemotherapy.
Knudsen P, Herborg H, Mortensen AR, et al. Qual Saf Health Care. 2007;16:285-90.
This study reports the results of root-cause analyses of medication errors reported by Danish pharmacies. Most errors occurred at the transcription stage, and a substantial proportion were attributed to poor handwriting.