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.
… safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive … future disruption though intentional training and building a culture of safety. … Goodwin C, Haas S, Berry W. What I wish I’d known: how experienced physician …
Weiseth A, Plough A, Aggarwal R, et al. Birth. 2022;49:637-647.
… Birth … Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to … effects on patient safety. … Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork during labor: …
Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.
Patient falls are an ongoing source of preventable harm, yet mitigating the fall risk of inpatients remains challenging. Conducted across three academic medical centers, this study evaluated the impact of a fall-prevention toolkit (Fall Tailoring Interventions for Patient Safety (Fall TIPS)). The Fall TIPS toolkit supports nurses in providing tailored, fall-prevention intervention and engages patients and families in fall prevention efforts. After implementation of Fall TIPS toolkit, there was a 15% reduction in falls and a 35% reduction in falls with injuries.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
… Jt Comm J Qual Patient Saf … As part of a quality improvement initiative to enhance surgical … 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. … little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe …
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.
Berry WR, Edmondson L, Gibbons LR, et al. Health Aff (Millwood). 2018;37:1779-1786.
This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.
Lagoo J, Berry WR, Miller K, et al. Ann Surg. 2019;270:84-90.
… 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were … informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons … behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as …
Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted.
Molina G, Berry WR, Lipsitz S, et al. Ann Surg. 2017;266:658-666.
… Annals of surgery … Ann Surg … Establishing a robust culture of safety , in which all staff feel free to … culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals … among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively …
Alidina S, Hur H-C, Berry WR, et al. Int J Qual Health Care. 2017;29:461-469.
This qualitative study used data from free-text survey comments to examine the effectiveness of surgical safety checklist implementation at 11 hospitals. Although most operating room staff viewed the checklist positively, obtaining buy-in for consistent checklist use by all staff remained challenging.
Cauley CE, Anderson G, Haynes AB, et al. Ann Surg. 2017;265:702-708.
… of surgery … Ann Surg … The large surge in opioid use is a serious patient safety problem. This retrospective study … opioid overdose increased over time. Patients with a substance abuse history were more likely to experience a postoperative opioid overdose, but hospital characteristics …
Haynes AB, Edmondson L, Lipsitz S, et al. Ann Surg. 2017;266:923-929.
… clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation …
Lashoher A, Schneider EB, Juillard C, et al. World J Surg. 2017;41:954-962.
… in mortality for the overall study population, they found a 50% reduction in mortality for patients with more severe … trauma injuries after implementation of the program. A prior PSNet perspective discussed components of an …