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.
Goldman J, Rotteau L, Flintoft V, et al. BMJ Qual Saf. 2023;32:470-478.
Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.
Jeffs L, Bruno F, Zeng RL, et al. Jt Comm J Qual Patient Saf. 2023;49:255-264.
Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.
As part of clinical learning, residents and trainees are sometimes allowed to make supervised mistakes when patient safety is not at risk. In this study, pediatric hospitalists describe potential benefits and risks of allowing failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen. Consistent with previous research, patient, trainee, team, and institutional factors were identified. Additionally, caregiver/parent factors were noted.
Klasen JM, Teunissen PW, Driessen E, et al. Med Educ. 2023;57:430-439.
Learning to recover after a medical error is an important component of medical training. This qualitative study, which included postgraduate trainees from Europe and Canada, concluded that failure represents a valuable learning opportunity, but noted the importance of perceived intentions if trainees judge that their supervisors have allowed them to fail.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;31:867-877.
… BMJ Qual Saf … Achieving high reliability is a goal for every healthcare organization. Based on interviews … types of healthcare professionals. … Rotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital …
Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2022;44:196-205.
Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.
Klasen JM, Lingard LA. Med Teach. 2019;41:1263-1269.
Learning from failure is more appropriate in some contexts than others. This review examined the use of learning from failures in postgraduate medicine and found further research is needed to understand how this strategy affects patient safety and learner resilience.
Ott M, Schwartz A, Goldszmidt M, et al. Med Educ. 2018;52:851-860.
This observation and interview study examined instances of surgical trainees hesitating in the operating room. Both trainees and attending physicians interpreted hesitation as incompetence. The authors suggest that this interpretation of hesitation does not support progressive autonomy for trainees and must be addressed in order to promote surgical safety.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13:98.
Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
Sears NA, Blais R, Spinks M, et al. BMC Health Serv Res. 2017;17:400.
… Adverse events occur frequently in the home care setting. A previous study estimated that about 10% of patients … experienced an adverse event, and research suggests that a significant proportion of these may be preventable . Early … dependency for instrumental activities of daily living and a higher number of comorbid medical conditions placed …
Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf. 2016;25:e7.
The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.
Wong BM, Dyal S, Etchells E, et al. BMJ Qual Saf. 2015;24:272-81.
… Saf … This prospective error investigation study combined a trigger approach to identify possible adverse events with … causes for adverse events. Investigators found that a myriad of factors contribute to adverse events, and … to prevent the detected events. The authors advocate for a framework to classify underlying causes together when they …
Parshuram CS, Amaral ACKB, Ferguson ND, et al. CMAJ. 2015;187:321-9.
This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.
Srigley JA, Furness CD, Baker R, et al. BMJ Qual Saf. 2014;23:974-980.
… BMJ Qual Saf … BMJ Qual Saf … Hand hygiene is a core practice for decreasing health care–associated … compared with hallway dispensers that were not visible by a direct observer. Since many publicly reported hand hygiene … these metrics may be greatly inflated and unreliable. A prior WebM&M perspective reviewed recent strategies for …
Doran DM, Baker R, Szabo C, et al. Int J Health Care Qual. 2014;26:136-143.
… Int J Qual Health Care … Int J Health Care Qual … Home care is one of the fastest growing … safety concerns among patients receiving home services. A prospective cohort study revealed that 10% of home care …
O'Beirne M, Reid R, Zwicker K, et al. J Patient Saf. 2013;9:211-8.
This study estimated a cost of approximately CAD $260,000 over 4 years to develop and run a safety learning system for family physician clinics in Calgary, Alberta. Policy makers and payers may need to determine whether there is an adequate return on investment for the sustainability of these types of programs.