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.
Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.
Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.
Vogus TJ, Singer SJ. Med Care Res Rev. 2016;73:660-672.
High reliability is a goal throughout health care. This commentary describes how lessons from high reliability organizations can be applied to accountable care organizations to enhance quality, reduce costs, and support population health. The authors describe ways to engage organizations in this work through mindfulness, leadership, and research.
Pakyz AL, Wang H, Ozcan YA, et al. J Patient Saf. 2021;17:445-450.
… J Patient Saf … J Patient Saf … Health care–associated infections (HAIs) are … Safety Score. … Pakyz AL, Wang H, Ozcan YA, Edmond MB, Vogus TJ. Leapfrog Hospital Safety Score, Magnet Designation, … Infections in United States Hospitals. J Patient Saf . 2017;10.1097/PTS.0000000000000378. …
High reliability organizations are those within high-risk industries that have adopted processes to detect and address failures before harm occurs. This survey study of nurses and nurse managers found that use of reliability-enhancing work practices, such as giving frontline employees mechanisms to recommend organizational change, is associated with fewer medication errors and falls. These results suggest that high reliability strategies can support patient safety.
Vogus TJ, Hilligoss B. BMJ Qual Saf. 2016;25:141-6.
High reliability has been an elusive goal for hospitals and care teams. This commentary examines habit as a mechanism to ensure that high performance practices are applied routinely during care delivery to enhance reliability.
Hilligoss B, Vogus TJ. Medical Care Research and Review. 2014;72.
This ethnographic study explored the underlying reasons for safety and communication problems at the transition of care between the emergency department and hospital wards. Through observation and interviews with physicians and hospital leadership, the study identifies structural and cultural barriers to effective communication and reveals time-consuming workarounds that physicians utilized to ensure patient safety.
Austin M, Jha AK, Romano PS, et al. Health Aff (Millwood). 2015;34:423-430.
One strategy to improve patient safety is public reporting of performance data, and hospital quality ratings have proliferated. In this study, researchers examined the extent of agreement among hospital ratings issued by U.S. News & World Report, HealthGrades, The Leapfrog Group, and Consumer Reports. Each rating system has a different emphasis, varying inclusion and exclusion criteria, and focuses on different measures of quality. There is very little agreement among the ratings for either high or low performance—not one hospital was rated as a top performer across all four ratings—which makes these ratings challenging for consumers to interpret or use in decision making. These findings are consistent with prior work demonstrating variability in surgical quality rankings. The authors call for transparency in how ratings are constructed and clear communication with consumers to facilitate informed decisions regarding their care. A recent AHRQ WebM&M interview with Leah Binder, President and CEO of The Leapfrog Group, explored the development of the Hospital Safety Score and Leapfrog Hospital Survey.
Vogus TJ, Cooil B, Sitterding M, et al. Med Care. 2014;52:870-6.
This cross-sectional study found that reports of nurses' safety organizing, behaviors meant to identify and address errors, were associated with decreased turnover and less emotional exhaustion, adding to the evidence for fostering a positive safety culture.
Austin M, D'Andrea G, Birkmeyer JD, et al. J Patient Saf. 2014;10:64-71.
Despite availability of multiple publicly reported patient safety accountability measures, a composite score for hospital safety has yet to be developed. The Leapfrog Group convened a panel of experts to develop such a score for hospitals in the United States. The group synthesized 26 distinct safety indicators into a score comprised equally of process measures (e.g., barcode medication ordering), which recognize safety efforts, and outcome measures (e.g., catheter-associated infections). The panel also weighted the metrics based on the strength of evidence, the opportunity for improvement (i.e., the variation in performance), and the impact (i.e., the potential number of patients affected). After calculating the score for all US hospitals for which data were available, they found lower scores for rural, publicly owned hospitals with a higher percentage of patients with Medicaid as their insurance.
Vogus TJ, Sutcliffe K. Med Care. 2007;45:997-1002.
Case studies of high-reliability organizations reinforce the importance of maintaining an organizational commitment and a culture of safety. This study discovered that extensive use of care pathways increased the positive effects of safety organizing. Investigators surveyed nurses and nurse managers and linked their responses to reported medication errors on a given unit. While limitations exist with error reporting data, the authors conclude that organizations should avoid focusing on technical and organizational factors in isolation, as benefit occurs from coupling strategies.