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.
Mahmoud HA, Thavorn K, Mulpuru S, et al. BMJ Open Qual. 2023;12:e002134.
Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.
Calder LA, Perry J, Yan JW, et al. Ann Emerg Med. 2021;77:561-574.
… strengthening dual diagnosis detection. … Calder LA, Perry J, Yan JW, et al. Adverse events among emergency department … study. Ann Emerg Med. Epub 2021 Feb 23. doi: 10.1016/j.annemergmed.2020.12.012. …
Sauro KM, Soo A, de Grood C, et al. Crit Care Med. 2020;48:946-953.
Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU) to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. JAMA Netw Open. 2019;2:e1910756.
Medication reconciliation aims to prevent adverse events after hospital discharge. In this cluster randomized trial, researchers evaluated the impact of an electronic medication reconciliation intervention involving automatic integration of community drug data and found that this process reduced medication discrepancies but did not reduce adverse events.
McIsaac DI, Hamilton GM, Abdulla K, et al. BMJ Qual Saf. 2020;29:209-216.
The AHRQ Patient Safety Indicators (PSIs), which are used to screen administrative data for patient safety events, have been revised in response to the new ICD-10 coding system. This study sought to validate the accuracy of ICD-10-based PSIs for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program reference standard. Although the PSIs had relatively high negative predictive value (meaning that the absence of a PSI meant that the patient likely had not experienced an adverse event), the overall accuracy was not sufficient to warrant using PSIs as the sole strategy to detect adverse events.
Forster AJ, Hamilton S, Hayes T, et al. Healthc Manage Forum. 2019;32:266-271.
The just culture paradigm shifts the response to error from a retrospective focus on blame to the system that contributed to the incident. This commentary describes one hospital's strategic and operational approach to just culture development and the results of the initiative.
Forster AJ, Huang A, Lee TC, et al. BMJ Qual Saf. 2020;29.
This prospective study used a trigger tool approach to identify potential adverse events among hospitalized patients in real time. Researchers found widely varying adverse rates among the five hospitals and concluded that event detection among the trigger event reviewers was responsible for some of the variation in observed events. These results underscore the challenge of accurate adverse event surveillance.
Santana MJ, Holroyd-Leduc J, Southern DA, et al. BMJ Qual Saf. 2017;26:993-1003.
Preventing adverse events after hospital discharge remains a top patient safety priority. In this randomized controlled trial, researchers found that the implementation of an electronic discharge communication tool did not significantly reduce death or readmission within 90 days of discharge.
Forster AJ, Bernard B, Drösler SE, et al. Int J Qual Health Care. 2017;29:548-556.
For the first time, the World Health Organization ICD-11 will include a taxonomy for quality and safety events. Researchers applied the new system to 45 patient safety vignettes gleaned from sources such as AHRQ WebM&M, then they described its strengths and limitations. Explicit identification of adverse events in administrative datasets could improve detection of errors, adverse events, and near misses on a population level.
Kobewka DM, van Walraven C, Turnbull J, et al. BMJ Qual Saf. 2017;26:141-149.
Inpatient mortality represents a key outcome measure in health care quality and safety. This study described the implementation of an institution-wide mortality review process, which identified significant opportunities to improve care, especially around discussing goals of care and delays in diagnosis.
Southern DA, Burnand B, Droesler SE, et al. Med Care. 2017;55:252-260.
AHRQ Patient Safety Indicators (PSIs) have been utilized to identify safety problems and suboptimal care quality in acute care settings using ICD-9 codes in administrative discharge data. Despite limitations in the accuracy of PSIs, they have been widely employed as a quality metric. The implementation of ICD-10 and diagnosis timing codes necessitate development of a new set of PSIs. This consensus and validation study used a Delphi panel process to determine ICD-10 codes associated with safety and quality concerns. Experts grouped the 640 identified diagnostic codes into 18 PSI categories. Application of these novel PSIs in over 10 years of hospital discharge data uncovered safety problems in 5% of hospitalizations. The authors recommend that these proposed PSIs should be further validated using record review or prospective case review.
Okoniewska B, Santana MJ, Holroyd-Leduc J, et al. BMC Health Serv Res. 2016;16:357.
Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.
Hewitt TA, Chreim S. BMJ Qual Saf. 2015;24:303-10.
A large body of literature shows that health care providers frequently fail to voluntarily report safety incidents. This qualitative study found that clinicians generally prefer to fix and forget safety problems rather than report them. This behavior is problematic in that it likely leads to clinicians developing workarounds instead of helping identify and solve underlying systems issues.
Calder LA, Pozgay A, Riff S, et al. BMJ Qual Saf. 2015;24:142-148.
This observational study examined all return emergency department visits within 7 days of an initial visit to determine if the second visit was caused by an adverse event. An adverse event was present in 12% of return visits that occurred within 72 hours of the initial visit. The authors suggest that this utilization pattern may be a promising trigger tool to identify adverse events.
Auger C, Forster AJ, Oake N, et al. BMJ Qual Saf. 2013;22:306-16.
Medication errors are one of the most common types of preventable adverse events in ambulatory care, but detecting them is challenging because, unlike hospitalized patients, ambulatory patients are not regularly monitored between visits. Telephone interactive voice response systems (IVRS), which place automated phone calls to patients, have been investigated as a means of detecting adverse events after discharge. This study reports on the feasibility of using IVRS to detect adverse drug events after patients received a new prescription from their primary care physician. The authors identified several limitations: the system only reached 70% of patients despite multiple events, and elderly patients in particular had more technical difficulty with the calls and were less likely to complete them successfully. Further refinement is needed before automated mechanisms can be used to reliably detect outpatient safety problems.