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.
Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.
Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.
Lagu T, Haywood C, Reimold KE, et al. Health Aff (Millwood). 2022;41:1387-1395.
People with disabilities face barriers to safe, equitable care such as inaccessible equipment and facilities or provider bias. In this study, primary care and specialist physicians described challenges with caring for patients with disabilities. Many expressed explicit biases such as reluctance to care for people with disabilities, invest in accessible equipment, or obtain continuing education to provide appropriate care.
Minyé HM, Benjamin EM. Br Dent J. 2022;232:879-885.
High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning.
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.
Grob R, Schlesinger M, Barre LR, et al. Milbank Q. 2019;97:176-227.
In this qualitative study, researchers analyzed narratives from a national sample of 348 patients. They conclude that patient narratives complement patient experience survey data and provide actionable information for quality improvement.
Kachalia A, Sands K, Van Niel M, et al. Health Aff (Millwood). 2018;37:1836-1844.
Health care systems have implemented communication-and-resolution programs (CRPs) to respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error disclosure, investigation into the cause, an apology, and early compensation. Some systems have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that CRPs will increase malpractice costs has limited widespread implementation. Investigators analyzed malpractice costs at four hospitals that implemented CRPs compared with matched control hospitals. Communication-and-resolution programs had either a positive or neutral effect on all metrics including new claims rate, paid claims rate, and total liability costs. This analysis is the most robust to date supporting CRP programs as previous studies have lacked a control group. A previous PSNet interview with Michelle Mello discussed other intersections between patient safety and the law.
Mello MM, Kachalia A, Roche S, et al. Health Aff (Millwood). 2017;36:1795-1803.
Communication-and-resolution programs, in which health systems and liability insurers disclose errors, apologize, and offer compensation to patients and families, led to declines in malpractice costs in prior studies. However, some have raised concerns that actual implementation of these programs may not have the same benefits. This prospective observational study reports results following implementation of a communication-and resolution-program at four hospitals in Massachusetts. Investigators report that the program was largely implemented as intended. Less than 10% of events met criteria for compensation, and the median payment was $75,000, allaying concerns about high costs of these programs. Lawsuits occurred in 5% of cases. The authors conclude that these results support further implementation and evaluation of communication-and-resolution programs. A recent PSNet interview with Michelle Mello, the lead author of this study, discussed legal issues in patient safety.
Martin J, Benjamin EM, Craver C, et al. J Patient Saf. 2016;12:125-31.
Patient safety problems can be difficult to detect. This study used electronic health record data—such as diagnostic codes, laboratory test values, and pharmacy information—to identify adverse events in an automated fashion. The authors conclude that the administrative harm measurement tool can detect adverse events accurately enough for internal quality improvement purposes, but the tool is insufficient to compare harm across institutions.
Preventing readmissions is a cornerstone of patient safety efforts. However, one concern about nonpayment for readmissions is that many may not be preventable. To determine whether they were preventable, this observational study investigated readmissions through patient and physician surveys along with chart review. Researchers determined that only one quarter of readmissions were preventable. Factors associated with potential preventability were premature hospital discharge, insufficient communication with outpatient providers, failure to discuss care goals, and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple interventions will be needed to avert readmissions, and such efforts will have limited impact since most readmissions are not preventable.
Lagu T, Goff SL, Craft B, et al. J Hosp Med. 2016;11:52-5.
Researchers in this study reviewed patient feedback posted on a hospital's Facebook page to determine whether social media may be a helpful mechanism for identifying patient safety and quality improvement issues. In this small sample of 37 respondents over a 3-week period, insights from social media comments did not seem to add much to the feedback already collected by more traditional methods, such as patient satisfaction surveys.
… patients in US hospitals each year depends on it. … PeterK. Lindenauer MD, MSc … Director, Center for Quality of Care … Engl J Med. 2012;367:1428-1437. [go to PubMed] 18. Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. …
This piece discusses efforts to promote the business case for safety and quality in health care.
Rothberg MB, Pekow PS, Liu F, et al. J Hosp Med. 2008;3:91-102.
This retrospective cohort study discovered that nearly 50% of patients received a potentially inappropriate medication (PIM) during hospitalization. Patients with myocardial infarction or heart failure were most likely to receive a PIM whereas men, those in managed care plans, and patients older than 85 were least likely.
Lindenauer PK, Rothberg MB, Pekow PS, et al. New Engl J Med. 2007;357:2589-2600.
Hospitalists are the fastest-growing medical specialty in the US, but their effect on quality of inpatient care has not been comprehensively assessed. This large observational study compared outcomes of patients cared for by hospitalists, general internists, and primary care physicians. Inpatient mortality and readmission rates were similar across all three groups of patients, and while hospitalists' patients had a slightly shorter length of stay, costs of care were also similar across groups. The study also did not find a relationship between case volume and outcomes.
Fitzgerald J, Kanter G, Benjamin EM. The Joint Commission Journal on Quality and Patient Safety. 2016;33.
This piece outlines steps taken by a large academic tertiary care facility to reduce surgical complications. Through its participation in a Surgical Infection Prevention (SIP) collaborative project, the hospital now places greater emphasis on improved reliability of processes, particularly in the use of antibiotics.
The pace of implementation of computerized physician order entry (CPOE) in U.S. hospitals has remained slow, and most prior research has taken place at academic hospitals where residents place most orders. This study measured physician-specific CPOE usage at two community hospitals where both CPOE and standard written order entry were allowed and surveyed attending physicians at those hospitals about their perceptions and usage of CPOE. The study revealed that nearly one-third of physicians still hand-wrote most of their orders, even if they had prior exposure to CPOE or used computers for personal activities. The authors discuss potential strategies to encourage "low users" to embrace CPOE.
Henneman PL, Blank FSJ, Smithline HA, et al. J Patient Saf. 2008;1:126-132.
The investigators studied an incentive-based voluntary reporting system in an emergency department and found that approximately half of errors were recovered, mainly by nurses, and that unrecovered errors impacted patients, most often with a delay in hospital stay.