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.
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.
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.
Martin HM, Navne LE, Lipczak H. BMJ Qual Saf. 2013;22:836-42.
The optimal role of patients in improving safety has yet to be determined. Although patients are being encouraged to ask questions and engage in safety programs, the extent to which patients are willing and able to do so is controversial. This qualitative study, conducted at a cancer center in Denmark, examined the perspectives of patients and health care professionals regarding patient engagement in safety efforts and strikes an important cautionary note. Despite the high-risk nature of oncology care, patients did not identify their safety as a main concern. While patients were observed engaging in safety behaviors—for example, questioning the dose of a new medication—most patients felt that ensuring safety was primarily the clinician's responsibility and expressed concern that more active involvement in safety could result in their being labeled "difficult" and could potentially impair their relationship with the care team. Given these findings, promotion of patient engagement in safety efforts runs the risk of merely shifting responsibility for safety from professionals to patients.
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.